A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

Choice A reason: Maintaining the infant in the supine position is not an appropriate intervention, as it can increase the pressure on the myelomeningocele sac and cause further damage to the spinal cord. The nurse should position the infant prone or side-lying, with the head turned to one side and the hips flexed.

Choice B reason: Limiting visitors to immediate family members is not a necessary intervention, as the infant does not have an infectious condition that requires isolation. The nurse should encourage the parents and other family members to visit and bond with the infant, and provide emotional support and education.

Choice C reason: Initiating contact precautions is not a required intervention, as the infant does not have a contagious condition that poses a risk of transmission to others. The nurse should follow standard precautions, such as washing hands, wearing gloves, and disposing of contaminated materials properly.

Choice D reason: Providing a latex-free environment is an essential intervention, as the infant has a high risk of developing a latex allergy due to the frequent exposure to latex products during surgery and other procedures. The nurse should avoid using latex gloves, catheters, syringes, bandages, or other items that contain latex, and use alternative materials instead. The nurse should also label the infant's chart, crib, and door with a latex allergy alert.

Choice A reason: This is a finding that the nurse should report to the provider. A pressure dressing is applied to the site of the catheter insertion to prevent bleeding and hematoma formation. If the dressing is saturated with bloody drainage, it indicates that the bleeding is not controlled and may lead to hemorrhage or infection.

Choice B reason: This is a finding that the nurse should report to the provider. Pulses of the extremity where the catheter was inserted should be equal to or stronger than the other extremity. If the pulses are diminished, it indicates that there is impaired blood flow to the extremity, which may be caused by arterial occlusion, thrombosis, or vasospasm.

Choice C reason: This is a finding that the nurse should report to the provider. The color and temperature of the extremity where the catheter was inserted should be similar to the other extremity. If the extremity is cool and pale, it indicates that there is inadequate perfusion to the extremity, which may be caused by the same factors as the diminished pulses.

Choice D reason: This is a finding that the nurse should report to the provider. Pain is an indicator of tissue damage or inflammation. The adolescent should have minimal or no pain after the procedure, as the site is numbed with local anesthesia. If the pain is present or increases, it indicates that there is a complication, such as bleeding, infection, or nerve injury.

Choice E reason: This is not a finding that the nurse should report to the provider. The apical pulse is the heart rate measured at the apex of the heart. It is a routine vital sign that the nurse should monitor after the procedure, but it is not a sign of a complication unless it is abnormal, such as too fast, too slow, or irregular. The nurse should compare the apical pulse with the baseline and the expected range for the adolescent's age and condition.