A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:

A. While the child’s oral intake is reduced, it is not as immediately critical as the other findings. However, it should still be monitored and managed.

B. The child’s blood pressure has dropped to 88/48 mm Hg on Day 3, which is significantly lower than the initial value and may indicate hypotension. This could be a sign of worsening condition or dehydration and needs to be reported for further evaluation and intervention.

C. The temperature of 38.1° C (100.6° F) on Day 3 indicates a fever but is lower than the initial admission temperature. It is important but not as critical as the other findings in this scenario.

D. The oxygen saturation has decreased to 88% on room air, which is below the normal range and indicates hypoxemia. This is critical in a patient with pneumonia and cystic fibrosis, and it requires immediate attention to manage respiratory function and oxygenation.

E. The child has passed three large, frothy, foul-smelling stools, which could be indicative of a gastrointestinal complication, possibly related to cystic fibrosis. This change in bowel habits should be reported as it may impact the child’s overall condition and treatment plan.

F. The sputum is thick, yellow, and blood-streaked, which is consistent with the condition but does not require immediate reporting unless there is a significant change in color or consistency.

G. The reported pain level of 4 on a scale of 0 to 10 is moderate but not life-threatening. It should be managed, but it is less urgent compared to other assessment findings.

H. The child is using accessory muscles for respiration and is experiencing dyspnea while at rest, which suggests worsening respiratory distress. This is crucial to report as it reflects the severity of the pneumonia and may need adjustments in the treatment plan.

A. A bulging fontanel indicates increased intracranial pressure or fluid overload, not dehydration. With dehydration, you expect a sunken fontanel.

B. Bradypnea (slow breathing) is not typically associated with dehydration and may indicate other issues.

C. A capillary refill time of 3 seconds suggests delayed perfusion, but it is not as indicative of severe dehydration as other signs.

D. Severity of dehydration is classified by percentage of body weight lost:Severe: ≥10% loss, moderate: 6–9% loss, mild: 3–5% loss. A 13% loss = severe dehydration, which matches the scenario.