A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

A. Hypotension: Methamphetamines are central nervous system stimulants that typically cause hypertension and tachycardia due to increased sympathetic activity, rather than low blood pressure.

B. Weight loss: Methamphetamines suppress appetite and increase metabolism, which can lead to significant weight loss. This is a common adverse effect associated with chronic use.

C. Somnolence: Stimulant effects of methamphetamines generally cause insomnia and hyperactivity rather than excessive sleepiness. Somnolence is not a typical adverse effect.

D. Lethargy: Methamphetamine use initially produces energy and euphoria. Lethargy may occur only during withdrawal, not as a direct adverse effect of active use.

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.