A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

A. Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B. Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C. Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D. Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E. Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F. Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G. Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H. Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I. Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J. Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.