A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?

The correct answer is choice c. Sunken anterior fontanel.

Choice A rationale:

A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.

Choice B rationale:

A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.

Choice C rationale:

A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.

Choice D rationale:

A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.

Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.

Choice A rationale

Meperidine is not the first choice for pain management in sickle cell crisis due to its potential to cause seizures and other side effects.

Choice B rationale

Bed rest is recommended during a sickle cell crisis to decrease the body’s demand for oxygen, reduce the workload of the heart, and improve blood flow.

Choice C rationale

Limiting fluid intake is not recommended during a sickle cell crisis. Adequate hydration is important to prevent further sickling of cells and to maintain kidney function.

Choice D rationale

Cold compresses can cause vasoconstriction and may exacerbate the crisis. Warm compresses are usually recommended to increase blood flow and reduce pain.