A nurse is providing care for a 3-month-old infant diagnosed with RSV bronchiolitis. The infant is tachypneic, rubbing his eyes, and appears sleepy.
The mother places the infant flat, but the baby becomes more short of breath and irritable. Which of the following is the best advice for the nurse to give?

Answer: D. Pulse of 150, poor skin turgor, oliguria, and an admission weight of 29.5 lbs. Rationale:

Choice A: A pulse of 160 is slightly elevated for a 3-year-old (normal range is 90-140 bpm), but not significantly so. Oliguria (decreased urine output) is a common sign of dehydration. However, sunken fontanels are typically seen in infants with severe

dehydration and not necessarily present in moderate cases. An admission weight of 30 lbs is irrelevant for assessing dehydration.

Choice B: A pulse of 180 is significantly elevated and suggests potential tachycardia, which can be a sign of severe dehydration or other underlying conditions. While a furrowed tongue can occur with dehydration, it's not specific enough. Mottled skin can be caused by various factors and isn't a definitive sign of moderate dehydration.

Admission weight alone isn't indicative of dehydration.

Choice C: A pulse of 120 is within the normal range for a 3-year-old. Dry mucous membranes are a common sign of dehydration. However, pale skin can be caused by various factors and isn't specific to dehydration. Admission weight alone isn't indicative of dehydration.

Choice D: A pulse of 150 is slightly elevated, potentially indicating dehydration or other factors. Poor skin turgor is a key assessment finding in moderate dehydration. It refers to the skin's slow return to its original shape after being pinched, indicating a lack of fluid. Oliguria is a common sign of dehydration, suggesting decreased fluid intake or output. An admission weight of 29.5 lbs might be slightly lower than the child's baseline weight due to dehydration, but weight alone shouldn't be used to diagnose dehydration.

Therefore, considering the combination of a slightly elevated pulse, poor skin turgor, oliguria, and a potential decrease in weight, choice D presents the most likely assessment findings in a child with moderate dehydration.

It's important to remember that a comprehensive assessment, including history, physical examination, and potentially laboratory tests, is crucial for diagnosing and classifying the severity of dehydration in children.

Choice A rationale

Administering enteral bolus feeds prior to surgery is not typically recommended for infants with a tracheoesophageal fistula. This is because the fistula can allow food or liquid to enter the trachea and lungs, leading to aspiration and potential respiratory complications.

Choice B rationale

Administering Famotidine prior to surgery can help reduce the risk of gastric acid reflux, which can lead to aspiration during surgery. This is particularly important in infants with a tracheoesophageal fistula, as the fistula can allow stomach contents to enter the trachea.

Choice C rationale

Administering IV antibiotics prior to surgery can help prevent infection. This is a common practice in many types of surgery, including surgery to repair a tracheoesophageal fistula.

Choice D rationale

Administering IV fluids during surgery can help maintain hydration and electrolyte balance. This is particularly important in infants, who have a higher risk of dehydration.

Choice E rationale

Administering 100% oxygen via a non-rebreather mask during surgery can help ensure that the infant has adequate oxygen levels. This is particularly important during surgery, as the infant will be under general anesthesia.