A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Pale and a 24-hr fluid deficit of 30 mL

Decreased appetite and irritability

Temperature 38° C (100.4° F) and pulse rate 124/min

Sunken fontanels and dry mucous membranes

Answer and Explanation

The Correct Answer is D

A.   A small fluid deficit of 30 mL is not concerning unless it worsens or additional symptoms develop.
B.   Decreased appetite and irritability can be expected with gastroenteritis and may not require immediate intervention.
C.   A mild fever and increased pulse rate can be expected, but if these values remain stable and other signs of dehydration or worsening illness are absent, they do not require immediate intervention.
D.   Sunken fontanels and dry mucous membranes are signs of dehydration and should be reported to the provider immediately.

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Correct Answer is B

Explanation

A. Administering an antiemetic might be appropriate later but does not address the potential cause of vomiting, which could be malfunctioning suction.
B. Evaluating the suction device is the priority to ensure it is working properly and preventing further vomiting.
C. Replacing the NG tube may be necessary if the tube is not functioning correctly, but the first step is to evaluate its effectiveness.
D. Providing oral hygiene care is important for comfort but does not address the immediate concern of suction malfunction.

A. Temperature 37.4° C (99.3° F) B. FHR baseline 170/min C. Early decelerations in the FHR D. Contractions lasting 80 seconds

Correct Answer is B

Explanation

A. A temperature of 37.4° C (99.3° F) is within the normal range during labor and does not require intervention.
B. A fetal heart rate (FHR) baseline of 170/min is elevated, which could indicate fetal distress, requiring further evaluation and intervention.
C. Early decelerations in the FHR are common during contractions and are not typically a cause for concern.
D. Contractions lasting 80 seconds are within the normal range for active labor and do not require reporting unless they become too frequent or intense.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

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