A 6-month-old infant is seen in the emergency department for dehydration related to vomiting. Upon assessment by the nurse, which of the following clinical assessments would be developed by an infant with a 12% fluid loss?

Cool and mottled extremities
Decreased skin turgor
Decreased urine output
Deep respirations

Explanation

• A fluid loss of 10% or more indicates severe dehydration. In addition to the signs and symptoms that develop during mild and moderate dehydration, the child would develop signs of shock. This includes hypotension, cool and mottled extremities, capillary refill of longer than 3 seconds, and lethargy.

• Mild dehydration (a fluid loss of 3 to 5%) often causes minimal or no symptoms. Patients can have a reduction in urine output.

• Moderate dehydration (a fluid loss of 6 to 9%) often causes tachycardia, orthostatic hypotension, decreased skin turgor, decreased urine output, deep respirations, dry mucous membranes, irritability, and sunken fontanels in infants.

Visit our website for other NCLEX topics now!