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:

Choice A rationale:

Oxygen saturation of 88% on room air is significantly below the normal range (95-100%) and indicates hypoxemia. This finding should be reported to the provider as it may require supplemental oxygen or other interventions.

Choice B rationale:

A heart rate of 128/min is elevated for a school-age child and may indicate increased work of breathing, fever, or other underlying issues. This finding should be reported to the provider for further evaluation.

Choice C rationale:

While the child reporting chest discomfort as 4 on a scale of 0 to 10 is important, it is not as critical as the other findings. The provider should be aware of the discomfort, but it may not require immediate intervention.

Choice D rationale:

An elevated WBC count of 15,000/mm³ indicates an infection, which is consistent with the diagnosis of bilateral pneumonia. While this is important information, it is expected in the context of the current diagnosis and may not require immediate reporting.

Choice E rationale:

Passing three large, frothy, foul-smelling stools is significant in a child with cystic fibrosis as it may indicate malabsorption or other gastrointestinal issues. This finding should be reported to the provider for further evaluation and potential adjustment of the treatment plan.

The correct answer is Choice D.

Choice A rationale

Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.

Choice B rationale

Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.

Choice C rationale

Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.

Choice D rationale

Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.