A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation.

Which of the following actions should the nurse take?

These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.

Choice B is wrong because a temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.

Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.

Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.

A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.

Normal ranges for vital signs in infants are as follows:

• Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
• Pulse rate: 100 to 160/min
• Respiratory rate: 30 to 60/min
• Blood pressure: 65/41 to 100/50 mm Hg

Normal ranges for fluid intake and output in infants are as follows:

• Fluid intake: 100 to 150 mL/kg/day
• Fluid output: 1 to 2 mL/kg/hr

The correct answer is choice C. “Perform chest percussion and postural drainage at least twice daily.” This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.

Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.

Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.

Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.

Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.

Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.