Exhibits

A nurse is caring for a school-age child who is dehydrated. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. Limiting the child’s fluid intake following the procedure is not necessary. Instead, encouraging oral fluids helps restore CSF volume and reduces the risk of post-lumbar puncture headache. Restricting fluids can worsen dehydration and delay recovery.

B. Positioning should not be prone during the procedure. The correct position is lateral recumbent with knees flexed to the chest or sitting with the head flexed. This widens the spaces between the vertebrae, allowing safe needle insertion into the subarachnoid space.

C. A signed consent form from the guardian is essential before a lumbar puncture. This ensures legal and ethical compliance, as the procedure is invasive and carries risks such as bleeding, infection, or spinal injury. The nurse must verify consent before proceeding.

D. Inserting an indwelling urinary catheter is not part of lumbar puncture preparation or procedure. Catheterization introduces unnecessary infection risk and is unrelated to collecting cerebrospinal fluid or managing patient safety during the test.

E. Applying pressure to the puncture site is required after needle withdrawal to reduce the risk of bleeding and CSF leakage. Maintaining pressure for several minutes supports clot formation and helps prevent complications such as hematoma.

F. Having the child void prior to the procedure is important for comfort and safety. The lumbar puncture may take time, and a full bladder can cause discomfort, interfere with positioning, or increase risk of accidental urine leakage during the test.

G. Monitoring for paresthesia or tingling after the procedure is crucial. These symptoms can indicate nerve irritation or trauma during needle insertion. Early detection allows prompt reporting and further evaluation to prevent long-term neurological complications.

Rationale for correct choices:

• Listless appearance: A shift from irritability to listlessness signals deteriorating clinical status. In toddlers, decreased responsiveness can reflect significant dehydration or hypoxemia. This neurological change is a red flag requiring urgent intervention.

• Wheezing and Audible Wheezing: Wheezing indicates a narrowing of the airways, which can be caused by inflammation or bronchospasm. While some wheezing was noted on Day 1, the fact that it is now "audible" suggests it is more severe, indicating worsening airway obstruction.

• Respiratory rate of 66/min: A normal respiratory rate for a 2-year-old is 25-30 breaths per minute. A rate of 66/min is tachypnea and is a compensatory to the toddler's inability to get enough oxygen. This high rate in conjunction with retractions indicates severe respiratory distress.

• Moderate subcostal retractions: Retractions are a key sign of respiratory distress. Moderate subcostal retractions indicate a significant increase in the work of breathing and are a red flag for respiratory failure.

• Blood pressure 82/40 mm Hg: This is hypotension for age and suggests poor perfusion from dehydration or sepsis. Hypotension in pediatrics is a late and ominous sign of shock. Rapid fluid resuscitation and close monitoring are priorities.

• Temperature 39° C (102.2° F): High fever significantly increases metabolic demand and oxygen consumption. In a toddler already in respiratory distress, it compounds the risk of hypoxemia and dehydration, requiring prompt antipyretic and supportive management.

Rationale for incorrect choices:

• Oxygen saturation 95% on room air: This oxygen level is within the acceptable range for a toddler, indicating oxygenation is still preserved. The focus should be on addressing worsening work of breathing and circulation, which pose more immediate risks.

• Apical heart rate regular, no murmur: A regular rhythm without a murmur is a normal finding in this context. It provides no evidence of acute hemodynamic instability and thus does not require urgent intervention.