Question

A nurse is caring for a 20-lb (9 kg) 6 month-old infant with a three-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated with 5% dextrose in 0.45% normal saline with 20 mEq of potassium per liter infusing at 35 mL/hr. Which finding should the nurse report to the health care provider immediately?

A. No measurable voiding in four hours
B. Periodic crying and irritability
C. Three episodes of vomiting in one hour
D. Vigorous sucking on a pacifier

Answer 1

The nurse should immediately report the lack of urine output in four hours to the healthcare provider as it could indicate severe dehydration.

Step-by-step explanation:

The nurse should report finding A. No measurable voiding in four hours to the health care provider immediately. This could be an indicator of dehydration, which is especially concerning in an infant with diarrhea, vomiting, and fever. Infants can dehydrate quickly, and absence of urine output is concerning in the context of intravenous therapy with potassium, as it can also affect kidney function and the body's electrolyte balance. Although the other symptoms provided (periodic crying and irritability, vomiting, and vigorous sucking) are relevant in the care of the infant, they do not represent as immediate of a threat to the infant's well-being as the potential for severe dehydration does.