A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

The correct answer is Choice A. Choice A rationale A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention. Choice B rationale While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated. Choice C rationale The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs. Choice D rationale The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .