A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Pale and a 24-hr fluid deficit of 30 mL

Sunken fontanels and dry mucous membranes

Temperature 38°C (100.4°F) and pulse rate 124/min

Decreased appetite and irritability

Answer and Explanation

The Correct Answer is B

A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.

B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.

C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.

D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.

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Correct Answer is A

Explanation

A. Correct. Having regular interdisciplinary team meetings allows healthcare professionals from various disciplines to collaborate, share information, and ensure coordinated care for the client with complex needs.
B. Noting changes in the treatment plan in the client's medical record is important, but it may not directly promote effective communication among staff.
C. Recording the client's progress in the nurses' notes is essential but may not address the need for communication among the entire care team.
D. Posting swallowing precautions at the head of the client's bed is important for the client's safety but does not directly address communication among staff members.

A. Use the balloon port to obtain the sterile specimen. B. Unclamp the collection port below the bag. C. Disconnect the catheter from the collection tubing. D. Obtain the specimen from the retention port.

Correct Answer is D

Explanation

A. The balloon port is used to inflate or deflate the catheter balloon and is not used for obtaining urine specimens.
B. Unclamping the collection port could contaminate the specimen with non-sterile urine from the tubing.
C. Disconnecting the catheter from the collection tubing could introduce contaminants into the catheter and tubing.
D. Correct. The retention port is a sterile access point on the catheter itself, and it can be used to obtain a sterile urine specimen without compromising the sterility of the collection system.

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A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

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