Question

A nurse in an ER is assessing a 3 mo infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

A. Capillary refill less than 2 seconds.
B. Fontanelle soft and flat.
C. Urine output of 6 wet diapers per day.
D. Moist mucous membranes.

Answer 1

The nurse should identify a marked decrease in urination as an indication that the infant has moderate to severe dehydration.

Step-by-step explanation:

The nurse should identify a marked decrease in urination as an indication that the infant has moderate to severe dehydration. Dehydration occurs when the body loses more fluids than it takes in, leading to a lack of water to function correctly. In infants, the body mass is low, so they can become dangerously dehydrated very quickly. Decreased urine output is a sign that the body doesn't have enough fluids to produce urine, indicating moderate to severe dehydration.

Other manifestations mentioned in the options are not indicators of moderate to severe dehydration. Capillary refill less than 2 seconds indicates good perfusion and hydration. A soft and flat fontanelle is a normal finding in a healthy infant. “Moist mucous membranes” is an expected finding in a well-hydrated individual.