A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
Explanation & Rationale
A. Blood pressure 94/68 mm Hg: While slightly on the lower end for a 7-year-old, mild hypotension may not yet be present in severe dehydration because children often maintain blood pressure until significant fluid loss occurs. Blood pressure alone is not the earliest or most sensitive indicator of severe dehydration. B. Urinary output 30 mL/hr: Normal urinary output for a child is approximately 1 mL/kg/hr. A child with severe dehydration typically has markedly reduced urine output (oliguria), so 30 mL/hr is still be within a low-normal range depending on the child’s weight C. Respiratory rate 24/mn: This respiratory rate is within normal limits for a 7-year-old (approximately 18–25 breaths/min). It does not reflect compensation for dehydration or hypovolemia and is not a reliable indicator of severe fluid loss. D. Heart rate 152/min: Tachycardia is an early and sensitive sign of hypovolemia in children. A heart rate of 152/min is significantly elevated for a 7-year-old, indicating compensatory mechanisms to maintain perfusion in response to severe dehydration.