A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Explanation & Rationale
Rationale: A. Sunken fontanels and dry mucous membranes: These findings indicate moderate to severe dehydration, which can quickly become life-threatening in an infant. Prompt notification of the provider is essential to initiate fluid replacement and prevent complications such as hypovolemic shock. B. Temperature 38° C (100.4° F) and pulse rate 124/min: A low-grade fever and mildly elevated pulse are common in gastroenteritis and typically do not require immediate reporting unless accompanied by other concerning symptoms like poor perfusion or lethargy. C. Pale and a 24-hr fluid deficit of 30 mL: A fluid deficit of 30 mL over 24 hours is minimal in an infant and not immediately concerning. Monitoring should continue, but urgent reporting is not necessary for this level of deficit. D. Decreased appetite and irritability: These are expected symptoms of gastroenteritis in infants and can be managed with routine supportive care and monitoring. They are not specific indicators of severe dehydration requiring immediate provider intervention.