A nurse is preparing to measure an infant’s vital signs.
The nurse should use which of the following sites to assess a heart rate?

The correct answer is Choice A.

Choice A rationale

A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.

Choice B rationale

A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.

Choice C rationale

Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.

Choice D rationale

A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.