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 the sunken anterior fontanelle as an indication of moderate to severe dehydration in the 3-month-old infant.

Step-by-step explanation:

The nurse should identify the sunken anterior fontanelle as an indication that the 3-month-old infant has moderate to severe dehydration. The anterior fontanelle is the soft spot on the top of a baby's head that usually closes by around 18 months of age. When the infant is dehydrated, the fontanelle may appear sunken due to the lack of fluid in the body.

Other manifestations of moderate to severe dehydration include a heart rate of 124 beats per minute (HR 124), indicating increased cardiac output to compensate for fluid loss; capillary refill of 2 seconds, suggesting poor peripheral circulation due to reduced blood volume; and decreased tear production as the body prioritizes maintaining fluid balance.