A nurse is caring for a toddler admitted to the hospital. Exhibits Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Body Systems Findings Respiratory Respiratory rate 26/min Cardiovascular Heart rate 112/min Capillary refill 4 seconds Gastrointestinal Hyperactive bowel sounds Integumentary Diaper area reddened with erythema noted Extremities cool Reports no tears Neurologic Lethargic

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock. Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation. Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues. Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management. Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.