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?

Step 1 is: Calculate the total volume to be infused. 150 mL/hr × 12 hr = 1800 mL Step 2 is: Calculate the total drops per minute. (1800 mL ÷ 720 min) × 20 gtt/mL = 50 gtt/min

The final calculated answer is 50 gtt/min.

The correct answer is C. Give the child acetaminophen for discomfort.

Choice A rationale

Offering clear liquids for the first 24 hours is not necessary after a cardiac catheterization. The child can resume a normal diet as tolerated unless otherwise instructed by the healthcare provider. Clear liquids are typically recommended after procedures involving the gastrointestinal tract to prevent nausea and vomiting, but this is not the case here.

Choice B rationale

Keeping the child home for a week is not required. The child can usually return to normal activities within a day or two, depending on the healthcare provider’s instructions. Prolonged rest is not necessary unless there are complications or specific instructions from the healthcare provider.

Choice C rationale

Acetaminophen is recommended for discomfort because it is effective in managing mild to moderate pain and has a low risk of side effects. It is important to avoid medications that can increase bleeding risk, such as aspirin or ibuprofen, especially after a procedure like cardiac catheterization.

Choice D rationale

Assisting the child to take a tub bath for the first 3 days is not recommended. It is generally advised to avoid submerging the catheter insertion site in water to prevent infection. Sponge baths are usually recommended until the site has healed.