A nurse is caring for a fussy 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Choice A rationale

Dehydration in infants can be a serious medical concern if not addressed quickly. It can be caused by various factors such as vomiting or diarrhea, or if the baby is not nursing well. The most common signs of dehydration in babies include concentrated urine that looks very dark yellow or orange, constipation, dry lips, dry mouth, dry mucous membranes, excessive sleepiness, irritability, less than six wet diapers in a 24-hour period, no interest in taking a bottle or breastfeeding, no tears when crying, paleness, sunken fontanelle (soft spot) on their head, and wrinkled skin. If the nurse observes these signs and symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might determine that the patient is dehydrated during the shift.

Choice B rationale

If the infant shows signs of improvement such as increased urine output, normal skin turgor, moist mucous membranes, and the infant is alert and active, then the nurse might determine that the patient is improving as anticipated. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice C rationale

Fluid volume excess, also known as fluid overload, occurs when the body has too much water and electrolytes. Symptoms can include swelling in the hands, feet, ankles, or abdomen, weight gain, high blood pressure, and shortness of breath. If the nurse observes these symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might

determine that the patient has fluid volume excess. However, given the information provided, this does not seem to be the most likely scenario.

Choice D rationale

If the infant’s vital signs are stable, the infant is alert and active, and there are no significant changes in the infant’s condition, the nurse might determine that the patient’s condition is stable. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.

Choice A rationale

Seizures, confusion, and weakness are symptoms that a nurse should anticipate when assessing a child suffering from hypotonic hyponatremia with a sodium level below 114

mEq/L2. Severe hyponatremia can lead to cerebral edema, resulting in neurologic symptoms such as seizures and confusion.

Choice B rationale

Mild tingling and numbness in fingers are not typically associated with hyponatremia. These symptoms are more commonly associated with conditions affecting the nervous system or with electrolyte imbalances such as hypocalcemia.

Choice C rationale

Frequent urination and fluid retention are not typical symptoms of hyponatremia. They are more commonly associated with conditions such as kidney disease or heart failure.

Choice D rationale

A temperature of 96°F orally and drowsiness are not specific symptoms of hyponatremia. While drowsiness can occur with severe hyponatremia due to cerebral edema, a low body temperature is not typically associated with this condition.