A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

Choice A reason: A 13% weight loss is a sign of severe dehydration in infants. Dehydration occurs when the body loses more fluid than it takes in. Acute gastroenteritis can cause vomiting and diarrhea, which can lead to fluid loss and dehydration.

Choice B reason: A bulging anterior fontanel is not a sign of dehydration, but rather a sign of increased intracranial pressure. The anterior fontanel is the soft spot on the top of the infant's head. It should be flat or slightly concave, not bulging or sunken.

Choice C reason: Bradypnea is not a sign of dehydration, but rather a sign of respiratory depression. Bradypnea is abnormally slow breathing, usually less than 12 breaths per minute in infants. Dehydration can cause tachypnea, which is abnormally fast breathing, usually more than 60 breaths per minute in infants.

Choice D reason: A capillary refill of 3 seconds is not a sign of dehydration, but rather a sign of normal perfusion. Capillary refill is the time it takes for the color to return to the nail bed after pressing on it. A normal capillary refill is less than 2 seconds. Dehydration can cause delayed capillary refill, which is more than 2 seconds.

Choice A reason: Withholding fluids until the client demonstrates a gag reflex is a preventive measure to avoid aspiration of liquids into the lungs. The gag reflex is a protective mechanism that prevents foreign objects from entering the airway. It can be impaired by anesthesia, surgery, or trauma. Therefore, the nurse should assess the client's gag reflex before offering fluids or food¹.

Choice B reason: Suctioning the nasopharynx as needed is another preventive measure to avoid aspiration of blood or secretions into the lungs. The nurse should monitor the client for signs of bleeding, such as frequent swallowing, restlessness, or bright red drainage. The nurse should also avoid stimulating the throat with tongue blades, straws, or suction catheters, as this can cause bleeding or spasm¹.

Choice C reason: Placing a bedside humidifier at the head of the client's bed is not a preventive measure to avoid aspiration, but rather a comfort measure to soothe the throat and reduce inflammation. Humidified air can help moisten the mucous membranes and promote healing. However, it does not prevent fluids or solids from entering the airway².

Choice D reason: Performing chest physiotherapy is not a preventive measure to avoid aspiration, but rather a treatment measure for clients who have respiratory complications, such as atelectasis or pneumonia. Chest physiotherapy involves percussion, vibration, and postural drainage to mobilize and remove secretions from the lungs. It is not indicated for clients who are postoperative following a tonsillectomy, as it can increase the risk of bleeding or pain³.

Choice E reason: Administering an antiemetic drug if the client is nauseous is a preventive measure to avoid aspiration of vomitus into the lungs. Nausea and vomiting are common postoperative complications that can be caused by anesthesia, pain, or opioids. The nurse should assess the client's nausea level and administer antiemetic drugs as prescribed. The nurse should also position the client on the side or with the head elevated to prevent aspiration¹.