A 3-year-old child is admitted to a pediatric unit with moderate dehydration.
The nurse would expect to see which of the following assessment findings in this child?

Choice A rationale

Positioning the infant on its abdomen after a cleft lip repair is not recommended. This position can put pressure on the surgical site and may lead to complications such as bleeding or infection.

Choice B rationale

Offering a pacifier to an infant who has just undergone a cleft lip repair is not advisable. The sucking motion can cause strain on the surgical site and may lead to complications such as dehiscence (separation of the wound edges) or infection.

Choice C rationale

Encouraging the parents to hold and comfort the infant is the best course of action. Holding provides comfort and security to the infant, which can help in reducing fussiness. Moreover, parental involvement in the care of the infant promotes bonding and has positive effects on the infant’s emotional and psychological well-being.

Choice D rationale

Administering Ibuprofen as needed for pain is not the best option. While Ibuprofen is a good analgesic, it is not the first choice for pain management in infants due to the risk of side effects. Moreover, pain management should be individualized, considering the infant’s age, weight, overall health status, and the nature and extent of the surgery.

Answer: D. Pulse of 150, poor skin turgor, oliguria, and an admission weight of 29.5 lbs. Rationale:

Choice A: A pulse of 160 is slightly elevated for a 3-year-old (normal range is 90-140 bpm), but not significantly so. Oliguria (decreased urine output) is a common sign of dehydration. However, sunken fontanels are typically seen in infants with severe

dehydration and not necessarily present in moderate cases. An admission weight of 30 lbs is irrelevant for assessing dehydration.

Choice B: A pulse of 180 is significantly elevated and suggests potential tachycardia, which can be a sign of severe dehydration or other underlying conditions. While a furrowed tongue can occur with dehydration, it's not specific enough. Mottled skin can be caused by various factors and isn't a definitive sign of moderate dehydration.

Admission weight alone isn't indicative of dehydration.

Choice C: A pulse of 120 is within the normal range for a 3-year-old. Dry mucous membranes are a common sign of dehydration. However, pale skin can be caused by various factors and isn't specific to dehydration. Admission weight alone isn't indicative of dehydration.

Choice D: A pulse of 150 is slightly elevated, potentially indicating dehydration or other factors. Poor skin turgor is a key assessment finding in moderate dehydration. It refers to the skin's slow return to its original shape after being pinched, indicating a lack of fluid. Oliguria is a common sign of dehydration, suggesting decreased fluid intake or output. An admission weight of 29.5 lbs might be slightly lower than the child's baseline weight due to dehydration, but weight alone shouldn't be used to diagnose dehydration.

Therefore, considering the combination of a slightly elevated pulse, poor skin turgor, oliguria, and a potential decrease in weight, choice D presents the most likely assessment findings in a child with moderate dehydration.

It's important to remember that a comprehensive assessment, including history, physical examination, and potentially laboratory tests, is crucial for diagnosing and classifying the severity of dehydration in children.