A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care?

This clinical picture suggests a complex fluid imbalance, likely involving both dehydration (evidenced by poor turgor and delayed capillary refill) and potentially a renal or nephrotic process (evidenced by periorbital and pitting edema). Tenting of the skin and a capillary refill of 4 seconds are late signs of significant fluid loss in children. The presence of edema alongside signs of dehydration often indicates a shift of fluid from the intravascular space to the interstitial space, commonly seen in conditions like nephrotic syndrome or severe protein-energy malnutrition.

Rationale for correct choices:

• Skin turgor with tenting: Poor skin turgor with tenting is an abnormal finding and commonly indicates dehydration or significant fluid imbalance. Even though the child has edema, fluid may be shifting from the intravascular space into the interstitial space, causing intravascular volume depletion. This can occur in conditions such as nephrotic syndrome where protein loss reduces oncotic pressure. The nurse should follow up because dehydration and poor perfusion can quickly worsen in children.

• Facial puffiness and swelling noted around the periorbital area: Periorbital edema is a significant abnormal finding often associated with renal disorders such as nephrotic syndrome or glomerulonephritis. It reflects fluid retention and altered fluid distribution caused by protein loss or impaired renal filtration. Facial puffiness in the morning is especially suggestive of kidney involvement in children. This requires prompt follow-up to assess renal status and fluid balance.

• +1 pitting edema noted in lower extremities: Pitting edema in a child is not considered a normal finding and suggests excess interstitial fluid accumulation. It may result from decreased plasma proteins, renal disease, or cardiovascular dysfunction. In combination with periorbital swelling and fatigue, this raises concern for nephrotic syndrome or another systemic disorder. The nurse should investigate further to determine the underlying cause and severity.

• Capillary refill 4 seconds: Normal capillary refill is usually less than 2 to 3 seconds, so 4 seconds indicates delayed peripheral perfusion. This may reflect dehydration, poor cardiac output, or reduced circulating blood volume despite visible edema. Delayed refill is especially concerning in children because it may signal worsening hemodynamic status. Immediate follow-up is needed to evaluate circulatory adequacy.

• Bowel sounds hyperactive in all 4 quadrants: Hyperactive bowel sounds are associated with increased intestinal motility and are often seen with diarrhea or gastrointestinal irritation. Since the child has loose stools and decreased oral intake, this finding supports ongoing GI fluid losses. Excessive bowel activity can worsen dehydration and electrolyte imbalance. The nurse should assess the duration, frequency, and cause of diarrhea.

• Last bowel movement yesterday was brown, loose, and liquid: Loose, liquid stool is abnormal and indicates diarrhea, which contributes to fluid and electrolyte losses. Persistent diarrhea in a child can quickly lead to dehydration, weakness, and poor nutritional intake. Combined with poor appetite and fatigue, this increases concern for worsening volume depletion. The nurse should follow up to assess stool frequency, possible infection, and hydration status.

Rationale for incorrect findings:

• Skin warm and dry to the touch: Warm, dry skin without fever or diaphoresis is generally not concerning and may be a normal finding. There is no indication of skin breakdown, infection, or abnormal temperature regulation. This finding alone does not suggest immediate instability. Compared to edema and dehydration indicators, it is not a priority concern.

• Heart rate regular without murmurs or gallops: A regular heart rate without murmurs or extra heart sounds indicates normal cardiac rhythm and no obvious signs of structural heart dysfunction on assessment. This is a reassuring cardiopulmonary finding and does not suggest acute cardiac compromise. Since no abnormal sounds are present, immediate follow-up is unnecessary.

• Abdomen soft, rounded, and nondistended: A soft, nondistended abdomen without tenderness is generally expected and does not indicate acute abdominal pathology. There is no sign of obstruction, guarding, or significant GI distress requiring urgent concern. This finding is not a priority compared to diarrhea and fluid imbalance.

Fall risk in pediatric clients is influenced by age, mobility, developmental stage, and conditions that affect balance, coordination, or vision. Toddlers are already at increased risk for falls because of developing motor skills, curiosity, and limited safety awareness. When a visual disturbance such as strabismus is present, depth perception and coordination may be impaired further. Nurses must identify children with the greatest fall risk to implement appropriate safety precautions and prevent injury.

Rationale:
A. An infant who has constipation is not at significant increased risk for falls because infants have limited independent mobility and are usually closely supervised. Constipation may cause discomfort or irritability, but it does not directly impair balance, vision, or ambulation. Therefore, it is not considered a major fall-risk factor.

B. A child who has asthma may require monitoring for respiratory distress, but asthma itself does not directly increase fall risk unless severe weakness or medication side effects are present. The condition mainly affects airway function rather than coordination or balance. Without additional complications, asthma is not the highest fall-risk diagnosis.

C. An adolescent who has neutropenia is at increased risk for infection rather than falls. Neutropenia reflects low neutrophil levels and requires infection prevention measures such as limiting exposure to pathogens. It does not inherently affect gait, vision, or motor coordination, so fall risk is not the primary concern.

D. A toddler who has strabismus is at greater risk for falls because misalignment of the eyes can interfere with depth perception and visual coordination. Toddlers are already prone to falls due to active exploration and immature motor control, and impaired vision increases this risk further. This combination makes fall prevention a priority for safety.