A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?

The correct answer is Choice B.

Choice A rationale

Encouraging deep breaths hourly can help prevent atelectasis and improve oxygenation, but it is not the priority in managing a vaso-occlusive crisis. The primary issue in a vaso-occlusive crisis is the blockage of blood flow due to sickled cells, leading to pain and potential organ damage. While deep breathing exercises are beneficial, they do not directly address the underlying cause of the crisis.

Choice B rationale

Maintaining fluids through an intravenous line is crucial in managing a vaso-occlusive crisis. Hydration helps to reduce blood viscosity, which can prevent further sickling of red blood cells and improve blood flow. Adequate hydration is essential to minimize the risk of complications such as stroke, acute chest syndrome, and organ damage. Therefore, maintaining IV fluids is a priority intervention in this scenario.

Choice C rationale

Beginning active range-of-motion exercises can help prevent joint stiffness and maintain mobility, but it is not the priority during an acute vaso-occlusive crisis. The primary focus should be on managing pain, ensuring adequate hydration, and preventing complications. Once the acute phase is managed, physical therapy and exercises can be introduced to support long- term health and mobility.

Choice D rationale

Seeing that the child ingests a protein-rich diet is important for overall health and growth, especially in children with chronic conditions like sickle cell anemia. However, during an acute

vaso-occlusive crisis, the immediate priority is to manage pain, ensure hydration, and prevent complications. Nutritional support can be addressed once the acute crisis is under control.

The correct answer is Choice C.

Choice A rationale

Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.

Choice B rationale

Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.

Choice C rationale

Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.

Choice D rationale

Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.