Pediatrics Question #15

Question

The parents of a 6-month-old reports that the child has been projectile vomiting for the past 3
hours. While lying in the parent’s arms, the nurse notices the infant is lethargic, has a pulse of
190/min and respirations of 60/min. What is most important for the nurse to report to the health
care provider?

Answers

  1. Infant has a recent history of severe gastroenteritis.
    • Rationale:
  2. Infant has been vomiting for approximately 3 hours.
    • Rationale:
  3. Infant has shown improvement from earlier distress.
    • Rationale:
  4. Infant is difficult to arouse with abnormal vital signs.
    • Rationale:

Overview

Explanation

The correct option is D. Rapid heart rate, respirations and the difficulty to arouse should be immediately reported to the health care provider. The infant is dehydrated and is showing signs of decline. The history of severe gastroenteritis is data that will need to be recorded as it could be the cause for the vomiting but does not take priority. The history of vomiting x 3 hours is concerning but does not take priority with the data provided. The status has changed in the infant and is important to note but does not take priority.

Learning Outcomes

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