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    Ati Rn Paediatrics 2023 Proctored Exam

    A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?

    Explanation & Rationale

    A. Weight loss of 5%: A 5% weight loss is typically indicative of mild to moderate dehydration, not severe.B. Sunken anterior fontanelle: A sunken anterior fontanel is a sign of severe dehydration in infants as it indicates significant fluid loss.C. Produces tears when crying: Producing tears is a sign of adequate hydration. Absence of tears would be more concerning for dehydration.D. Capillary refill time 3 seconds: A capillary refill time of 3 seconds is at the upper limit of normal for infants. In severe dehydration, capillary refill time would typically be longer than 3 seconds.

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