A nurse is caring for a toddler.

Exhibits

Which of the following findings require immediate follow-up by the nurse?

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0920:

Toddler is irritable, sitting on guardian's lap. Clear drainage draining from nose. Oral mucosa dry. Cervical lymph nodes nonpalpable. Lung sounds clear in all lung fields. Nonproductive, occasional cough present. Apical heart rate regular, no murmur. Capillary refill 3 seconds. Abdomen nontender, bowel sounds hyperactive.

Previous weight (4 weeks ago) 12 kg (26.5 lb)

Current weight 11.4 kg (25 lb)

Vital Signs

0910:

• Temperature 39.6° C (103.2° F)
• Blood pressure 88/42 mm Hg
• Heart rate 150/min
• Respiratory rate 28/min
• Oxygen saturation 96% on room air

Rationale for Correct Choices

• Toddler is irritable: Irritability in a young child is a red flag for worsening systemic illness, dehydration, or early hypoxia, and requires close observation and intervention.
• Oral mucosa dry: This is a classic clinical sign of dehydration. It indicates that the toddler's body is losing more fluids than it's taking in, leading to a fluid volume deficit.
• Temperature 39.6° C (103.2° F): A persistent high fever in a toddler increases the risk of dehydration and febrile seizures. It requires prompt intervention with antipyretics and fluids to prevent further complications.
• Blood pressure 88/42 mm Hg: This is hypotension for a 2-year-old, suggesting compromised perfusion. Immediate action is needed as this can indicate progressing dehydration or early septic shock.
• Heart rate 150/min: Tachycardia in toddlers may indicate dehydration, fever, or compensatory response to low blood pressure. If unaddressed, it can progress to cardiovascular instability.
• Capillary refill 3 seconds: Prolonged refill indicates poor peripheral perfusion, which often accompanies dehydration or hypovolemia. This is a red flag for impaired circulation and worsening shock.
• Weight loss from 12 kg to 11.3–11.4 kg: A loss of nearly 6% body weight in a short period is clinically significant dehydration in a toddler. This requires prompt fluid replacement to avoid further decline.

Rationale for Incorrect Choices

• Respiratory rate 28/min: This rate is within the normal range for a 2-year-old (20–30 breaths/min). Without distress, retractions, or desaturation, it does not require immediate follow-up.
• Oxygen saturation 96% on room air: This is an acceptable oxygen level in a toddler. There are no signs of hypoxemia or respiratory compromise requiring intervention.
• Apical heart rate regular, no murmur: A regular rhythm without abnormal sounds indicates stable cardiac function. No immediate follow-up is required here.
• Lung sounds clear in all fields: The absence of wheezing, crackles, or diminished sounds rules out acute respiratory distress, so no intervention is immediately required.