A nurse in a provider's office is assessing the vital signs of a 2-year-old child at a well-child visit.
Which of the following findings should the nurse report to the provider?

Choice A rationale:

Showing teeth while smiling assesses the facial nerve (cranial nerve VII), not the accessory nerve (cranial nerve XI) The facial nerve controls facial expressions, including smiling.

Choice B rationale:

Following a light in the six cardinal positions assesses extraocular eye movements, which are controlled by the oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI) This action does not assess the accessory nerve.

Choice C rationale:

Shrugging the shoulders against mild pressure assesses the function of the accessory nerve (cranial nerve XI) The accessory nerve controls the sternocleidomastoid and trapezius muscles, which are responsible for head rotation and shoulder shrugging. Assessing the strength of these muscles helps evaluate the integrity of the accessory nerve.

Choice D rationale:

Moving the tongue in all directions assesses the hypoglossal nerve (cranial nerve XII), which controls tongue movements. This action does not assess the accessory nerve.

The correct answer is d. Weight loss 7%.

Choice A reason: Respiratory rate 28/min. The normal respiratory rate for infants can vary depending on their age. For newborns, it’s typically between 30-60 breaths per minute1. As they grow older, the rate decreases. For example, infants aged 0-5 months have a normal respiratory rate of 25-40 breaths per minute. Therefore, a respiratory rate of 28/min falls within the normal range for an infant and does not specifically indicate moderate dehydration.

Choice B reason:. Bradycardia in infants is defined as a heart rate that is slower than normal for their age. For infants aged 0-3 years, a heart rate less than 100 beats per minute is considered bradycardia3. Bradycardia can be a sign of many conditions, including dehydration, but on its own, it is not a definitive indicator of moderate dehydration.

Choice C reason: Capillary refill time is the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. In infants, a normal capillary refill time is less than 2 seconds, and in newborns, it can be up to 3 seconds. A capillary refill time of 1 second is within the normal range and does not indicate moderate dehydration.

Choice D reason: Weight loss 7%. In infants, a weight loss of about 6-9% is generally considered a sign of moderate dehydration. This is because infants are particularly susceptible to fluid loss due to their small body size and higher body water content. A 7% weight loss in an infant who has rotavirus, which can cause significant fluid loss through diarrhea, is a strong indicator of moderate dehydration.