Question

The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33%

normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours

Answer 1

No measurable voiding in 4 hours should be reported immediately as it indicates a serious risk of dehydration and may require urgent medical intervention. The correct answer is option D).

Step-by-step explanation:

The finding that should be reported to the health care provider immediately for a 6 month-old infant with a history of diarrhea, occasional vomiting, and fever, currently receiving intravenous therapy, is D) No measurable voiding in 4 hours.

This could indicate a serious risk of dehydration, which can be life-threatening in infants and may require urgent medical intervention to restore fluid balance. While episodes of vomiting and irritability are also concerning and should be monitored, the lack of urination is a critical sign that the infant's condition may be worsening.

This is especially important to address since maintaining proper fluid and electrolyte balance is crucial in pediatric patients. The healthcare provider must be notified so that they can assess the situation and adjust the treatment plan, which may include modifying the IV fluid rate.