Question

A nurse in an emergency department is assessing a 3-month-old 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. HR 124
b. increased tear production
c. sunken anterior fontanel
d. capillary refill 2 seconds

Answer 1

The nurse should identify a sunken anterior fontanel as an indication that the infant has moderate to severe dehydration.

Step-by-step explanation:

The nurse should identify a sunken anterior fontanel as an indication that the infant has moderate to severe dehydration. When a 3-month-old infant has rotavirus and is experiencing acute vomiting and diarrhea, dehydration can be a serious concern. The anterior fontanel is the soft spot on the top of an infant's head. If it appears sunken, it is a sign of dehydration.