Pediatric Assessment & Vital Sign Norms by Age (Pediatrics)

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

1. Overview: Kids Are Not Small Adults

Airway: smaller and narrower; a little swelling causes a big drop in airflow. Infants are preferential nose breathers — nasal congestion can cause real distress
Breathing: higher metabolic rate and less oxygen reserve → they desaturate fast
Circulation: children keep BP normal by raising HR and constricting vessels. Hypotension is a late, ominous sign of shock — tachycardia, delayed cap refill, and mental status changes come first
Fluids: higher body water percentage and higher turnover → dehydrate quickly
Temperature: large surface area → heat loss
Pediatric arrests are usually respiratory in origin — fix the airway and breathing early

2. Pediatric Assessment Triangle (PAT) — The “From the Doorway” Look

Side	Look for
Appearance (TICLS)	Tone, Interactiveness, Consolability, Look/gaze, Speech/cry
Work of breathing	Abnormal sounds (stridor, grunting, wheeze), , nasal flaring, head bobbing, tripod position
Circulation to skin	Pallor, mottling, cyanosis

Any abnormal side → act now (ABCs) before the detailed exam.

3. Vital Sign Norms (approximate — ranges vary by source and facility)

Age	Heart rate (awake)	Respiratory rate	Systolic BP (approx.)
Newborn (0–1 mo)	100–205 (often taught 110–160 resting)	30–60	60–85
Infant (1–12 mo)	100–180	30–53	70–100
Toddler (1–2 yr)	98–140	22–37	85–105
Preschool (3–5 yr)	80–120	20–28	89–112
School-age (6–11 yr)	75–118	18–25	97–115
Adolescent (12–15+ yr)	60–100	12–20	105–130

Ranges loosely follow PALS/AHA reference tables; sleeping rates are lower, crying/fever raise them.

Hypotension cutoff (PALS): term neonate SBP < 60; infant < 70; age 1–10: < 70 + (2 × age in years); > 10 yr: < 90 mmHg
Temperature: fever ≥ 38.0 °C (100.4 °F). Any fever in an infant < 28–60 days old (per protocol) is an emergency workup (sepsis risk). Rectal is most accurate in infants; avoid rectal in neutropenia, after rectal surgery, or with diarrhea per policy. Tympanic is unreliable < 6 months
Count RR and apical HR for a full minute in infants and young children. Do the least invasive steps first (RR while calm/asleep, then HR, then temperature)
Pulse oximetry: generally ≥ 94–95% on room air; follow orders for target (bronchiolitis protocols may accept ≥ 90%)
BP cuff: bladder width ~40% of upper arm circumference, length covering 80–100%. Too small → falsely high

4. Approach by Age

Age	Tips
Infant	Exam on parent’s lap; auscultate when quiet; save invasive parts (ears, mouth, temp) for last; check fontanelles
Toddler	Minimal contact first; let them touch equipment; parent holds; quick
Preschool	Explain with simple words; “play” with stethoscope; give choices; head-to-toe is OK
School-age	Explain purpose; respect modesty; can be head-to-toe
Adolescent	Interview alone for part of visit (HEADSSS: Home, Education/employment, Activities, Drugs, Sexuality, Suicide/depression, Safety); privacy and confidentiality within legal limits

5. Pain Assessment

Scale	Ages
FLACC (Face, Legs, Activity, Cry, Consolability)	~2 months – 7 years, or nonverbal/cognitively impaired
NIPS / PIPP	Neonates/preterm
Wong-Baker FACES	~3 years and up
Numeric 0–10	~8 years and up (who understand numbers)

Nonpharmacologic comfort: sucrose and non-nutritive sucking/breastfeeding for infant procedures, swaddling, skin-to-skin, distraction, topical anesthetics (EMLA/LMX — apply ahead per product), vapocoolant sprays, buzzy devices, comfort positioning (parent holding child upright, not restrained flat).

6. Medication Safety in Children

Doses are weight-based (mg/kg) — weigh in kilograms and document in kg only. 1 kg = 2.2 lb
Always check that the ordered dose is within the safe range before giving. Example: amoxicillin 40 mg/kg/day divided q12h for a 15-kg child = 600 mg/day = 300 mg per dose
Use oral syringes (never household spoons); give liquids in the inner cheek in small amounts; don’t mix in large food volumes (child may not finish)
IM sites: vastus lateralis in infants/toddlers; deltoid in older children (~3 yr+, enough muscle mass); needle length based on size
IV safety: use a volume-control chamber (buretrol) and pump; check sites hourly (infiltration is easy to miss)
Avoid aspirin in children/teens with viral illness (Reye syndrome); avoid codeine and tramadol in children < 12 (and in some teens) due to dangerous respiratory depression
Acetaminophen and ibuprofen are weight-dosed; ibuprofen generally not for infants < 6 months unless prescribed

7. Signs of Deterioration — Act Now

Increasing work of breathing, grunting, head bobbing, decreasing RR or HR in a tired child (impending arrest)
Lethargy, poor response to parents, inconsolability or weak cry
Delayed capillary refill > 2–3 s, mottling, cool extremities, weak peripheral pulses
Low urine output: < 1 mL/kg/h in infants/children (< 0.5 mL/kg/h adolescents) — weigh diapers (1 g = 1 mL)
Bulging fontanel, petechial/purpuric rash, seizure

8. Memory Aids

“Kids crash late and hard” — compensated shock hides behind normal BP
Hypotension: “70 + 2 × age” (ages 1–10)
PAT = “A, B, C from the door”: Appearance, Breathing work, Circulation to skin
Least invasive to most invasive: “Look, listen, touch, poke”
FLACC for the little/nonverbal; FACES at 3; numbers at 8

9. NCLEX-Style Practice Questions

1. A 6-year-old has a systolic BP of 74 mmHg, HR 150, cap refill 4 seconds, and is lethargic. How should the nurse interpret this?

A. Normal findings for age
B. Compensated shock
C. Hypotensive (decompensated) shock — an emergency
D. Anxiety

Answer: C. Hypotension cutoff for age 6 = 70 + (2 × 6) = 82 mmHg. SBP 74 with tachycardia, delayed refill, and lethargy means decompensated shock — call for help, support ABCs, prepare for fluid resuscitation.

2. In what order should the nurse assess a calm sleeping 8-month-old?

A. Temperature, heart rate, respiratory rate
B. Respiratory rate, heart rate, temperature
C. Ears, throat, heart rate
D. Heart rate, temperature, respiratory rate

Answer: B. Count respirations first while the infant is quiet, then apical HR, and save invasive or upsetting steps (temperature, ears, throat) for last.

3. A provider orders acetaminophen 240 mg PO for a 16-kg child. The safe dose is 10–15 mg/kg/dose. What should the nurse do?

A. Give the dose — it is within the safe range
B. Hold and clarify — the dose is too high
C. Hold and clarify — the dose is too low
D. Give half the dose

Answer: A. 16 kg × 10–15 mg = 160–240 mg. 240 mg is at the top of the safe range, so it can be given. Always check the daily maximum and other acetaminophen sources too.

4. Which pain scale is most appropriate for a 2-year-old after surgery?

A. Numeric 0–10
B. FLACC
C. Wong-Baker FACES
D. Visual analog scale

Answer: B. FLACC is a behavioral scale for young or nonverbal children. FACES generally starts around age 3; numeric scales need number concepts.

5. Which findings in a 10-month-old with gastroenteritis require immediate follow-up? Select all that apply.

A. Capillary refill of 4 seconds
B. HR 130 while calm
C. Sunken anterior fontanel
D. One wet diaper in 12 hours
E. Smiling and playing with toys

Answer: A, C, D. Delayed cap refill, a sunken fontanel, and markedly low urine output signal significant dehydration. HR 130 is within normal infant range, and playful behavior is reassuring.

References

American Heart Association. (2020). Pediatric advanced life support provider manual. American Heart Association.

Daley, S. F., & Avva, U. (2024). Pediatric dehydration. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436022/

Fleming, S., Thompson, M., Stevens, R., Heneghan, C., Plüddemann, A., Maconochie, I., Tarassenko, L., & Mant, D. (2011). Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. The Lancet, 377(9770), 1011–1018. https://doi.org/10.1016/S0140-6736(10)62226-X

National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page