A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.
Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

The correct answers are Choices B, D, E, and F.

Choice A rationale:

Administering promethazine 50 mg intermittent IV bolus is not typically indicated for managing acute abdominal pain and suspected appendicitis. Promethazine is an antiemetic and antihistamine, but it does not address the underlying cause of the symptoms.

Choice B rationale:

Obtaining informed consent for surgery is crucial as the client’s symptoms and lab results (elevated WBC count and C- Reactive Protein) strongly suggest appendicitis. Surgery, specifically an appendectomy, is the definitive treatment for appendicitis.

Choice C rationale:

Administering acetaminophen 800 mg may help alleviate pain and reduce fever, but it does not address the underlying cause of the symptoms. It is important to manage the pain, but the primary focus should be on diagnosing and treating the appendicitis.

Choice D rationale:

Initiating IV antibiotics is essential in managing suspected appendicitis to prevent infection and complications such as perforation or abscess formation. Antibiotics help control the infection until surgical intervention can be performed.

Choice E rationale:

Maintaining NPO (nothing by mouth) status is important to prepare the client for potential surgery and to prevent exacerbation of symptoms. Keeping the client NPO helps reduce the risk of aspiration during anesthesia and surgery.

Choice F rationale:

Obtaining an abdominal ultrasound is important to confirm the diagnosis of appendicitis. Imaging studies such as ultrasound or CT scan can help visualize the appendix and assess for inflammation or other abnormalities.

Choice G rationale:

Administering enemas until clear is not appropriate in this scenario. Enemas are not indicated for managing acute abdominal pain and suspected appendicitis. They could potentially worsen the condition or mask important symptoms.

The correct answer is Choice C.

Choice A rationale

Auscultating for a cardiac murmur can be helpful but is not the most specific assessment for coarctation of the aorta. Murmurs can be present in various cardiac conditions.

Choice B rationale

Recording blood pressure in the upper extremities alone is not sufficient. Coarctation of the aorta often presents with a discrepancy between upper and lower extremity blood pressures.

Choice C rationale

Assessing for the presence of femoral pulses is crucial. In coarctation of the aorta, there is decreased blood flow to the lower extremities, leading to weak or absent femoral pulses.

Choice D rationale

Observing for excessive crying is non-specific and can be associated with many conditions, not just coarctation of the aorta.