A nurse is caring for an infant who has rotavirus.
Which of the following findings indicates that the infant is moderately dehydrated?

The correct answer is d. Exhibits head lag when pulled to a sitting position.

Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.

Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.

Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.

Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.

Cleanse the gums with saline-soaked gauze.

This can help keep the mouth moist and clean, which is important for preventing infection and promoting healing of oral ulcers caused by chemotherapy.

Choice A is wrong because routine oral care should be performed more frequently than every 8 hours.

Choice B is wrong because lemon glycerin swabs can dry out and irritate the mucosa.

Choice C is wrong because oral viscous lidocaine should not be used in children due to the risk of toxicity.