A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

Rationale for correct choices:

• Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
• Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

• Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
• Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
• Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
• Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
• Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
• Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.

B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.

C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.

D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.