A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?

Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.

Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.

Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.

Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.

Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.

Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.

This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.

Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.

Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.

Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.

Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.