A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Choice A: Performing range of motion on the infant's hips is not appropriate for an infant who has myelomeningocele, which is a type of spina bifida that causes a sac-like protrusion of the spinal cord and nerves through an opening in the spine. Performing range of motion on the infant's hips can cause nerve damage or pain in the lower extremities, which may already be affected by the condition.

Choice B: Taking an axillary temperature is appropriate for an infant who has myelomeningocele, as it is a non-invasive and accurate method of measuring body temperature. An axillary temperature is taken by placing a thermometer under the armpit and holding the arm close to the body. Taking an axillary temperature can help monitor for signs of infection or inflammation, which are common complications of myelomeningocele.

Choice C: Placing the infant in a side-lying position is not appropriate for an infant who has myelomeningocele, as it can cause pressure or friction on the sac and increase the risk of rupture or infection. The correct position for an infant with myelomeningocele is prone with hips slightly flexed and legs abducted. This position can prevent trauma and promote drainage from the sac.

Choice D: Maintaining a dry dressing over the sac is not appropriate for an infant who has myelomeningocele, as it can cause irritation or infection of the sac and surrounding skin. The correct dressing for an infant with myelomeningocele is moist and sterile with saline or antibiotic solution. This dressing can prevent drying and cracking of the sac and reduce bacterial growth.

Choice A: Irregular respiratory rate is not a reliable indicator of mild dehydration, as it can be affected by many factors such as fever, infection, pain, or anxiety. An irregular respiratory rate can also indicate more severe dehydration or shock, which requires immediate intervention.

Choice B: Good skin integrity is not a reliable indicator of mild dehydration, as it can be maintained even in moderate dehydration. Good skin integrity does not reflect the fluid status of the body, as skin turgor and elasticity depend on other factors such as age, nutrition, and hydration.

Choice C: Blood pressure elevation is not a reliable indicator of mild dehydration, as it can be caused by other conditions such as stress, anxiety, pain, or hypertension. Blood pressure elevation can also indicate more severe dehydration or shock, which requires immediate intervention.

Choice D: Body weight is the most reliable indicator of mild dehydration, as it reflects the fluid loss or gain of the body. A loss of 5% or more of body weight indicates mild dehydration in infants. Body weight should be measured daily and compared with the baseline weight to monitor the fluid status of the infant.