# A 3-year-old child has been experiencing severe diarrhea for 3 days with signs of moderate dehydration: decreased skin turgor, dry mucous membranes, and decreased urine output. The parents ask about fluid management. What is the most appropriate initial nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542044  
> language: ko  
> subject: Child Health

## 문제

A 3-year-old child has been experiencing severe diarrhea for 3 days with signs of moderate dehydration: decreased skin turgor, dry mucous membranes, and decreased urine output. The parents ask about fluid management. What is the most appropriate initial nursing intervention?

## 보기

1. Encourage the parents to give the child clear liquids like apple juice and soda to replace lost fluids
2. Administer oral rehydration solution (ORS) containing appropriate electrolyte concentrations as prescribed **✔ 정답**
3. Recommend withholding all oral intake until the diarrhea completely stops to rest the bowel
4. Suggest giving the child milk-based products to provide nutrition and calcium replacement

**정답: 2**

## 해설

Oral rehydration solution (ORS) is the gold standard for treating moderate dehydration in children with diarrhea, as it contains optimal sodium and glucose for absorption. Clear liquids like apple juice can worsen diarrhea, withholding oral intake exacerbates dehydration, and milk-based products may cause lactose intolerance.

## 심화 해설

Understanding the Clinical Scenario

This question presents a classic pediatric nursing priority: managing a 3-year-old with acute gastroenteritis leading to moderate dehydration. The key assessment findings—decreased skin turgor, dry mucous membranes, and decreased urine output—are hallmark signs of significant fluid volume deficit. The core of the question tests your ability to select the safest, evidence-based initial fluid replacement strategy, distinguishing it from common but harmful lay practices.

Why Oral Rehydration Solution (ORS) is the Correct Initial Intervention

The most appropriate nursing intervention is to administer oral rehydration solution (ORS) containing appropriate electrolyte concentrations as prescribed. This is the established standard of care for acute diarrhea in pediatric patients, a recommendation grounded in decades of global health data [1]. The physiological rationale is rooted in the function of the intestinal sodium-glucose cotransporter 1 (SGLT1). Diarrhea does not destroy this cotransport mechanism; therefore, when ORS with a precise ratio of glucose to sodium is given, glucose facilitates the absorption of sodium, and water follows passively by osmosis. This mechanism allows for effective rehydration even in the presence of ongoing fluid losses. The primary goal of initial management is to reduce mortality and prevent progression to severe dehydration, a goal for which ORS is demonstrably effective [1]. While ORS does not reduce the duration or volume of diarrhea—a factor that can reduce caregiver compliance—its life-saving capacity in the acute phase makes it the non-negotiable first step [1].

Analysis of Incorrect Options

The incorrect options represent common misconceptions that can actively harm a pediatric patient.

- Option 1 (Clear liquids like apple juice and soda): This is dangerous due to the high osmolality and inappropriate carbohydrate-to-sodium ratio. Fluids like apple juice and soda have a high simple sugar content and very low sodium. The excess sugar creates a high osmotic load in the gut lumen, which paradoxically pulls water into the intestine and can worsen osmotic diarrhea, exacerbating dehydration and electrolyte imbalances. They are not a substitute for the precise formulation of ORS.

- Option 3 (Withhold all oral intake to "rest the bowel"): This outdated practice is contraindicated. The intestinal epithelium requires luminal nutrients for enterocyte repair and regeneration. Withholding oral intake deprives the gut of these substrates, prolongs villous atrophy, and can worsen malnutrition. Early refeeding and continued hydration with ORS are critical components of current guidelines.

- Option 4 (Milk-based products for nutrition and calcium): This is inappropriate during acute gastroenteritis. Diarrheal illness often causes a transient deficiency in the enzyme lactase, which is located at the tips of the intestinal villi. Introducing milk-based products can lead to lactose malabsorption, causing increased gas, bloating, and osmotic diarrhea, thereby worsening the clinical picture. While nutritional support is important, it should initially come from age-appropriate, easily digestible foods, not from milk-based products that may exacerbate symptoms.

Connecting to Advanced Pathophysiology and Future Therapies

The limitations of current ORS therapy, as highlighted in the provided evidence, offer a deeper insight into the disease process. A major shortcoming is that while ORS corrects dehydration, it does not directly address the secretory diarrhea mechanism, leading to a lack of symptom relief and reduced caregiver compliance [1]. The research points to the intestinal calcium-sensing receptor (CaSR) as a master regulator of fluid transport. Activation of CaSR by agonists like calcium or polyamines can inhibit fluid secretion and promote absorption, effectively turning off the "faucet" of secretory diarrhea [1]. This explains why future therapies may target CaSR to both rehydrate and reduce stool output. In a clinical context, this underscores why a nurse’s role includes not only administering ORS but also educating caregivers that the diarrhea will continue, managing expectations to prevent premature abandonment of the life-saving therapy. Furthermore, in cases of severe acute malnutrition with gastroenteritis, the decision to use intravenous fluids is complex and historically cautioned against due to the risk of fluid overload, though newer evidence is actively investigating this balance to improve outcomes in this high-mortality group .References (research sources)

- [1]Inability to reduce morbidity of diarrhea by ORS: can we design a better therapy?Research articleHarrell JE, Cheng SX. (2018) · DOI: 10.1038/pr.2017.295

## 임상 시나리오

Clinical Guideline: Pediatric Acute Gastroenteritis

First-Line Therapy: Oral rehydration solution (ORS) is the cornerstone of treatment for mild to moderate dehydration in children with acute diarrhea. The World Health Organization (WHO) and CDC recommend standard osmolarity ORS (e.g., 245 mOsm/L) with a specific glucose-to-sodium ratio to optimize the SGLT1 cotransport mechanism.

Administration Protocol: For moderate dehydration, administer 50–100 mL/kg of ORS over 2–4 hours. Use a teaspoon, syringe, or dropper to give small, frequent volumes (e.g., 5 mL every 1–2 minutes) if the child is vomiting. Reassess hydration status hourly.

Fluids to Avoid: Do not use apple juice, soda, sports drinks, or plain water. These are hyperosmolar or lack adequate sodium, potentially worsening hyponatremia and osmotic diarrhea. Milk-based products may cause transient lactose malabsorption and should be reintroduced cautiously after rehydration.

Nutritional Support: Continue breastfeeding or age-appropriate feeding as soon as the child is rehydrated. Early refeeding with complex carbohydrates, lean proteins, and yogurt helps restore enterocyte function and reduces illness duration.

Monitoring Parameters: Track strict intake and output, daily weight, urine specific gravity, and clinical signs (skin turgor, mucous membranes, mental status). Return to emergency care if the child develops severe dehydration, altered consciousness, or intractable vomiting.

## 핵심 개념

- **Acute Gastroenteritis** — Acute gastroenteritis. Inflammation of the gastrointestinal tract caused by viruses (e.g., rotavirus, norovirus) or bacteria, leading to diarrhea, vomiting, and abdominal pain.
- **Moderate Dehydration** — Moderate dehydration. About 5-10% of body weight has been lost. Signs include decreased skin turgor, dry mucous membranes, reduced tears, and decreased urine output.
- **Oral Rehydration Solution** — Oral rehydration solution. A solution containing water, glucose, sodium, potassium, and chloride in specific proportions, which allows efficient absorption of water and electrolytes through the intestinal sodium-glucose cotransporter.
- **Skin Turgor** — Skin turgor. It is an important physical examination finding used to assess dehydration. It is evaluated by the speed at which the skin returns to its original state after gently pinching and releasing the skin on the abdomen or thigh. It becomes slower in dehydration.
- **Sodium-Glucose Cotransport** — Sodium-glucose cotransport. This is the mechanism by which the transporter (SGLT1) in the small intestinal epithelial membrane uses the sodium ion concentration gradient to transport glucose into the cell. This is the physiological basis for the effectiveness of ORS.

## 같은 주제 문제

- [A 5-year-old child is brought to the emergency department with a 3-day history of severe d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542040)
- [A 2-year-old child is brought to the emergency department with a 3-day history of watery d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542041)
- [A 4-year-old child is brought to the emergency department with a 3-day history of severe d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542042)
- [A 2-year-old child is admitted to the pediatric unit with severe diarrhea and dehydration.…](https://mymerci.kr/pages/nclex_q.php?qn_id=542043)
- [A 2-year-old child is admitted to the pediatric unit with severe diarrhea and dehydration.…](https://mymerci.kr/pages/nclex_q.php?qn_id=542045)
- [A 3-year-old child is admitted to the pediatric unit with severe diarrhea for the past 3 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542046)
- [A 4-year-old child is admitted to the pediatric unit with severe diarrhea for the past 3 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542047)
- [A 2-year-old child is admitted to the pediatric unit with severe diarrhea for the past 3 d…](https://mymerci.kr/pages/nclex_q.php?qn_id=542048)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._