A nurse is caring for a 3-year-old toddler who has dehydration.
Which of the following findings should the nurse report to the provider?

The correct answer is D

Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.

Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.

Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.

Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.

• A: Obtain the latex free cart is incorrect. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.
• B: Paralytic ileus is incorrect. Paralytic ileus is not the primary condition that the client is experiencing, but a possible secondary complication of malignant hyperthermia.
• C: Nausea and vomiting is incorrect. Nausea and vomiting are common postoperative symptoms that may or may not be related to malignant hyperthermia.
• D: Hypercapnia is incorrect. Hypercapnia is a condition of elevated carbon dioxide levels in the blood that can result from hypoventilation or respiratory failure. The client's respiratory rate is high, not low, indicating hyperventilation rather than hypoventilation.
• E: Nasogastric (NG) tube is incorrect. An NG tube may be indicated for paralytic ileus or bowel obstruction, but not for malignant hyperthermia.
• F: Malignant hyperthermia is correct. The client's vital signs indicate a possible malignant hypertermia reaction, which is a rare but life-threatening complication of general anesthesia that causes a rapid rise in body temperature, muscle rigidity, tachycardia, tachypnea, and hypoxia.
• G: Administer ondansetron is incorrect. Ondansetron is an antiemetic medication that can help with nausea and vomiting, but it does not address the underlying cause of malignant hyperthermia.
• H: Administer dantrolene is correct. Dantrolene is the antidote for malignant hyperthermia and should be given as soon as possible to stop the metabolic crisis and lower the body temperature.
• I: Latex allergy is incorrect. Latex allergy is a hypersensitivity reaction to latex products that can cause urticaria, angioedema, bronchospasm, or anaphylaxis. There is no evidence that the client has a latex allergy or that latex exposure triggered the malignant hyperthermia reaction.
• J: Urticaria is incorrect. Urticaria is a skin rash that can be caused by allergic reactions, infections, or other factors. There is no evidence that the client has urticaria or that it is related to malignant hyperthermia.
• K: Muscle rigidity is correct. Muscle rigidity is one of the signs of malignant hyperthermia and should be monitored closely by the nurse.
• L: Bowel sounds is correct. Bowel sounds should be assessed regularly by the nurse to detect any signs of paralytic ileus, which is a potential complication of malignant hyperthermia that causes intestinal obstruction and abdominal distension.