Sunken fontanelle with capillary refill >3 seconds indicates severe dehydration requiring immediate IV fluids, as it shows significant fluid loss and poor perfusion. Other options are less urgent findings of moderate or mild dehydration.
심화 해설
Understanding Dehydration Assessment in Infants with Gastroenteritis
When an infant presents with vomiting and diarrhea, the priority nursing responsibility is to accurately assess hydration status and recognize findings that signal progression toward hypovolemic shock. The question asks which single assessment finding is most concerning and demands immediate intervention — this is a clinical judgment question testing your ability to prioritize based on physiological urgency.
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Analyzing Each Assessment Finding
Option 1: Sunken fontanelle with delayed capillary refill of 4 seconds
A sunken fontanelle reflects loss of cerebrospinal fluid and interstitial volume due to significant fluid depletion. However, the critical element here is the capillary refill time (CRT) of 4 seconds. Normal CRT in infants is ≤2 seconds. A delay to 4 seconds indicates compromised peripheral perfusion, which is a late and ominous sign of hypovolemic shock. At this point, compensatory mechanisms (tachycardia, peripheral vasoconstriction) are failing to maintain cardiac output and tissue oxygenation. This finding represents decompensated or severe hypovolemic shock and requires immediate fluid resuscitation — typically with isotonic intravenous boluses — without delay. This is the most concerning finding.
In the study by Tariverdi et al. , dehydration severity in children with acute gastroenteritis was systematically assessed by pediatricians, and clinical parameters including capillary refill were key discriminators of severe cases requiring hospitalization.
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Option 2: Decreased urine output with concentrated appearance
Oliguria (urine output
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