A 6-month-old infant is brought to the emergency department by parents who report that the child has been vomiting for the past 8 hours. Which assessment finding would be the nurse's priority concern?
1Decreased appetite and fussiness
2Vomiting occurring 2-3 times per hour
3Sunken fontanelle and decreased skin turgor✓ 정답
4Temperature of 99.2°F (37.3°C)
해설
Sunken fontanelle and decreased skin turgor indicate significant dehydration in infants, a life-threatening complication of persistent vomiting requiring immediate IV fluids. Other options are less urgent findings.
Clinical Judgment
This question assesses the Recognize Cues and Prioritize Hypotheses stages. Vomiting for 8 hours is an important cue, but you must evaluate its consequences rather than the symptom itself. Infants have low fluid volume and a fast metabolism, so dehydration can progress rapidly. The sunken fontanelle and decreased skin turgor in option 3 are objective and reliable signs indicating moderate or greater dehydration. This is the highest-priority danger signal, requiring immediate fluid replacement.
Memory Tip:
For assessing infant dehydration, remember Fontanelle, Urine output, Mucous membrane, Tears, Skin turgor — First Urgent Matters To See (FUMTS).
KR vs US:
In Korea, there may be a greater focus on immediate testing (e.g., ultrasound) for the cause of vomiting (e.g., gastroenteritis, intussusception), but in NGN/CJMM, the core approach is to first determine and stabilize the severity of the patient's condition (degree of dehydration). Assess ABCs (Airway, Breathing, Circulation) and fluid status before investigating the cause.
Clinical Practice Guide
When assessing dehydration in infants, the percentage of weight loss is the most accurate indicator. Clinically, you should comprehensively evaluate the condition of the anterior fontanelle, presence of tears, moisture of the oral mucosa, urine output, and vital signs (especially heart rate). A sunken anterior fontanelle indicates that a significant amount of fluid has already been lost.
Caution:
For option 2 ("vomiting 2-3 times per hour"), it is difficult to judge severity based on frequency alone. The key factors are the volume and characteristics of the vomit (bilious, bloody), and most importantly, whether there are accompanying signs of dehydration. Do not be misled by the frequency alone.
Dehydration — A state where excessive loss of body water makes it insufficient to maintain physiological functions. It is dangerous in infants as it can progress rapidly.
Sunken Fontanelle — Soft spot where the sutures of an infant's skull meet. If sunken, it is an important sign of fluid volume deficit (dehydration).
Skin Turgor — Skin turgor. When dehydrated, the skin returns slowly or "tents" when pinched.
Intussusception — A condition where a segment of the intestine telescopes into an adjacent intestinal segment, causing acute intestinal obstruction. It is characterized by "currant jelly stool", paroxysmal pain, and vomiting, and may be an underlying cause of this problem.
Hypovolemic Shock — Shock caused by a rapid decrease in circulating blood volume. It is a life-threatening complication that can occur when severe dehydration progresses.