Ati Lpn Paediatrics (Nursing Care Of Newborn) Proctored Exam
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)Exhibit 1Exhibit 2Exhibit 3 Graphic RecordBlood pressure 68/46 mm Hg Heart rate 182/min Respiratory rate 32/minTemperature 38.8°C (101.9°F) SaO2 95% on room air
Explanation & Rationale
Rationale:A. Skin turgor assessment is important in assessing dehydration, but the priority is addressing the tachycardia first.B. Potassium level is important in managing electrolyte imbalance in gastroenteritis, but the priority is addressing the elevated heart rate first.C. Capillary refill is an important assessment for circulation, but the priority is addressing the elevated heart rate first.D. The elevated heart rate (tachycardia) indicates increased workload on the heart, likely due to dehydration or other complications of gastroenteritis. This requires immediate attention to stabilize the infant's condition.
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