A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)Exhibit 1

Exhibit 2

Exhibit 3 Graphic Record
Blood pressure 68/46 mm Hg Heart rate 182/min Respiratory rate 32/min
Temperature 38.8°C (101.9°F) SaO2 95% on room air

Rationale:

A) Rubbing betadine on the infant's incisions is not typically done after surgical repair of a cleft lip and palate, as it can cause irritation and delay wound healing.

B) Placing the infant in a prone position for an extended period is not recommended after cleft lip and palate repair surgery, as it may increase the risk of airway obstruction and compromise wound healing.

C) Weighing the infant daily using the same scale helps monitor for changes in fluid status and overall health status following surgery.

D) Suctioning the infant's nose and mouth may be necessary to maintain airway patency, but it should be done judiciously to avoid trauma to the surgical site.

Rationale:

A. Monitoring capillary refill of the casted extremity is crucial for assessing circulation and ensuring there are no complications such as compartment syndrome.

B. While supporting the cast correctly is important, it is not the priority immediately following the application.

C. Examining the skin at the cast edges is important, but it is not the priority immediately following the application.

D. Instructing the child not to put anything inside the cast is important, but it is not the priority immediately following the application.