# 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. What is the most important initial assessment the nurse should perform? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542035 > language: ko > subject: Child Health ## 문제 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. What is the most important initial assessment the nurse should perform? ## 보기 1. Check the infant's temperature and assess for signs of infection 2. Assess the infant's hydration status and skin turgor **✔ 정답** 3. Evaluate the infant's feeding pattern and recent dietary changes 4. Examine the infant's abdomen for distension and bowel sounds **정답: 2** ## 해설 Assessing hydration status is the priority for infants with vomiting due to their high risk of rapid dehydration. Other assessments like temperature, feeding patterns, or abdominal exam are important but secondary to preventing life-threatening complications. ## 심화 해설 Clinical Context and Priority Setting A 6-month-old infant with an 8-hour history of vomiting presents a classic clinical scenario where the nurse must rapidly identify the most immediate threat to physiological stability. In pediatric patients, particularly infants, the body’s proportion of total body water is significantly higher than in adults, and their renal concentrating ability is immature. This means that fluid losses from vomiting can rapidly lead to hypovolemia and electrolyte imbalances. The principle of triage and initial assessment in any vomiting child prioritizes the evaluation of perfusion and hydration because decompensation can occur quickly and silently [2]. Why Hydration Assessment Takes Priority The correct answer is to assess the infant's hydration status and skin turgor. This assessment directly evaluates the infant’s circulatory volume and the degree of fluid deficit, which is the primary determinant of immediate management. In acute gastroenteritis, a common cause of vomiting in this age group, the severity of dehydration guides all subsequent therapeutic decisions, from the route of fluid replacement to the need for hospitalization [2]. Checking skin turgor on the abdomen or thigh, assessing the moisture of mucous membranes, noting the presence or absence of tears, and evaluating the anterior fontanelle are rapid, non-invasive bedside assessments that provide critical data on the percentage of body weight lost as fluid. A delay in recognizing moderate to severe dehydration can lead to hypovolemic shock, a life-threatening complication . Analysis of Other Options While the other assessments are components of a thorough evaluation, they are not the most important initial action. Checking the infant's temperature and assessing for signs of infection (Option 1) addresses the potential etiology of the vomiting, such as rotavirus, which is a major cause of acute gastroenteritis in children under five [2]. However, identifying a fever or an infectious source does not immediately quantify the physiological impact of the fluid loss that has already occurred. Similarly, evaluating the infant's feeding pattern and recent dietary changes (Option 3) is relevant for identifying a non-infectious cause but is a secondary historical detail that does not supersede the need to assess the child’s current hemodynamic stability. Examining the infant's abdomen for distension and bowel sounds (Option 4) is essential for ruling out surgical emergencies like intussusception or obstruction, but an 8-hour history of vomiting without reported bilious content or severe pain makes a primary surgical pathology less immediately life-threatening than the potential for severe dehydration. The foundational nursing guideline for a vomiting child is to first determine "how dry" the patient is, not "what made them sick," because the management of dehydration is time-sensitive and directly prevents deterioration . Pathophysiology and Clinical Correlation The danger of ongoing vomiting lies in the loss of isotonic fluid, which depletes the extracellular compartment. In infants, a loss of just 5% of body weight can manifest as clinical dehydration, and a loss of 10% or more constitutes severe dehydration with a risk of shock. The assessment of skin turgor, a key component of Option 2, is a direct reflection of interstitial fluid volume. When the skin on the infant’s abdomen is gently pinched and released, a delayed return ("tenting") indicates a significant fluid deficit. This physical sign, combined with other markers like a sunken fontanelle and prolonged capillary refill, allows the nurse to rapidly classify the dehydration severity as mild, moderate, or severe [2]. This classification is the cornerstone of clinical decision-making, as it dictates whether oral rehydration therapy is appropriate or if immediate intravenous access and fluid resuscitation are required. Congenital conditions, such as congenital hyperinsulinism, can also present with vomiting and dehydration, further underscoring that the assessment of fluid and metabolic status is the critical first step in uncovering the underlying pathology .References (research sources) - [2]Rotavirus-associated acute gastroenteritis in children under five years: a cross-sectional study from southern Iran.Research articleTariverdi M, Tamaddondar M, Hooshyar D, Fallahi M, Rahmati MB, Hakami MM, Asgari A, Abdollahi H. (2026) · DOI: 10.18502/ijm.v18i3.21664 ## 임상 시나리오 Clinical Practice Guide: Initial Assessment of the Vomiting Infant In a 6-month-old with an 8-hour vomiting history, the priority is to rule out life-threatening hypovolemia. The following structured approach ensures rapid identification of shock and guides immediate fluid resuscitation. 1. Rapid Hydration Assessment - **Skin Turgor:** Pinch skin on the abdomen or thigh. Tenting (slow return >2 seconds) indicates moderate-to-severe dehydration. - **Mucous Membranes:** Dry or sticky oral mucosa suggests significant fluid deficit. - **Fontanelle:** A sunken anterior fontanelle is a late and critical finding. - **Tears & Urine Output:** Absence of tears and decreased wet diapers are key historical and physical indicators. 2. Classify Dehydration Severity - **Mild (3-5% loss):** Slightly dry mucosa, alert, normal skin turgor. - **Moderate (6-9% loss):** Delayed skin turgor, sunken eyes, irritable, tachycardia. - **Severe (>10% loss):** Tenting skin, lethargic, hypotensive, delayed capillary refill. This is a medical emergency requiring immediate IV access. 3. Critical Nursing Actions - **Weigh the Infant:** Obtain an accurate, undressed weight and compare to recent pre-illness weight to calculate fluid loss percentage. - **Vital Signs:** Tachycardia is often the earliest sign of hypovolemia; hypotension is a late and ominous sign. - **Ongoing Monitoring:** Strict intake and output, daily weights, and frequent reassessment of perfusion markers (capillary refill, mental status). Secondary assessments for the etiology (e.g., infection, surgical abdomen, dietary causes) are performed only after the patient's hemodynamic stability is confirmed or concurrently during resuscitation. ## 핵심 개념 - **Skin turgor** — A measure of skin elasticity used to assess dehydration; in infants, it is best tested on the abdomen or thigh. - **Hypovolemia** — A state of decreased intravascular blood volume, which in infants can rapidly result from vomiting and lead to shock. - **Anterior fontanelle** — The soft spot on an infant's head; a sunken fontanelle is a late sign of significant dehydration. ## 같은 주제 문제 - [A 4-month-old infant is brought to the emergency department by parents who report that the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542036) - [A 6-month-old infant is brought to the emergency department by parents who report that the…](https://mymerci.kr/pages/nclex_q.php?qn_id=542037) - [A 65-year-old patient with a history of diabetes is admitted with persistent vomiting for …](https://mymerci.kr/pages/nclex_q.php?qn_id=542038) - [A 4-year-old child is admitted to the pediatric unit with persistent vomiting for the past…](https://mymerci.kr/pages/nclex_q.php?qn_id=542039) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._