# An 18-month-old with gastroenteritis completes a 4-hour oral rehydration trial. Which reassessment findings require immediate follow-up? Highlight the appropriate cells.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=en  
> language: en  
> subject: Complications of Procedures  
> category: ROR

## Question

An 18-month-old with gastroenteritis completes a 4-hour oral rehydration trial. Which reassessment findings require immediate follow-up? Highlight the appropriate cells.

| Reassessment area | Finding after the 4-hour trial |
| --- | --- |
| Oral intake | The child takes 75% of the planned ORS in frequent small amounts and reaches for the next spoonful without prompting. |
| Circulation | Capillary refill improves from 4 to 3 seconds but remains 3 seconds after the feet are warmed; pedal pulses are faint. |
| Heart rate | Heart rate falls from 142/min on arrival to 118/min while the child sits quietly with warm hands and unchanged respiratory effort. |
| Mucous membranes | The lips remain dry, but the tongue is moist and tears are present during a venipuncture attempt. |
| Emesis | One 15-mL emesis follows a rapidly offered cup; the next six teaspoon-sized doses stay down over 30 minutes. |
| Urine output | No wet diaper occurs during the trial; the caregiver confirms the last one was 7 hours ago. |
| Eyes and skin | The eyes appear less sunken, an abdominal skin pinch returns immediately, and the caregiver says the child's appearance is closer to baseline. |
| Behavior | The child now requires repeated touch to awaken for ORS after being interactive 1 hour ago. |
| Stool losses | Two watery stools occur, and measured replacement ORS is given after each stool without further emesis. |

## Explanation

Persistent perfusion delay after warming, no urine for 7 hours, and a new decline in responsiveness show that oral rehydration has not restored safe hydration. The other findings show tolerance or improvement.

## In-depth explanation

Quick answer
Highlight the circulation, urine-output, and behavior findings. The pattern is incomplete perfusion recovery, markedly reduced urine output, and a new change in responsiveness after the oral rehydration trial.

Why this is correct
Pediatric dehydration is assessed from a cluster and its trend, not from one dry lip or one tolerated drink. Capillary refill that remains prolonged after warming, faint pulses, decreased urine output, and worsening responsiveness are red flags for clinically important dehydration or progression toward shock.[1][2]

Easy analogy or mental picture
Think of oral rehydration as a test run. Keeping down some solution matters, but the test has not succeeded if circulation, kidney output, and alertness still move in the wrong direction.

Memory hook
After ORS, reassess the trend: perfusion, urine, responsiveness.

NCLEX decision rule
After an intervention, prioritize findings that show failure to restore circulation or a new neurologic decline. Do not let improving intake, tears, or one retained dose cancel a worsening multisystem trend.

Why the other choices are wrong
Taking most of the planned ORS, a calm heart rate that improves from admission, moistening oral findings, retention of later small doses, improving eyes and skin recoil, and replaced stool losses all support continued reassessment rather than immediate escalation by themselves.References

- [1]NICE: Gastroenteritis in Children Under 5—RecommendationsNational Institute for Health and Care Excellence

- [2]CDC: Managing Acute Gastroenteritis Among ChildrenCenters for Disease Control and Prevention

- [3]2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

## Related questions

- [A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet…](https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=en)
- [A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterizat…](https://mymerci.kr/pages/nclex_q.php?qn_id=368186&lang=en)
- [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=en)
- [A 38-week newborn is delivered limp, apneic, and cyanotic. Place the steps of Neonatal Res…](https://mymerci.kr/pages/nclex_q.php?qn_id=372738&lang=en)
- [A 64-year-old patient three days post-MI has BP 84/62, HR 124, distant heart sounds, jugul…](https://mymerci.kr/pages/nclex_q.php?qn_id=372747&lang=en)
- [A patient is one day post-thoracotomy with a chest tube connected to a closed-chest draina…](https://mymerci.kr/pages/nclex_q.php?qn_id=372755&lang=en)
- [A nurse is implementing an evidence-based surgical site infection (SSI) prevention bundle …](https://mymerci.kr/pages/nclex_q.php?qn_id=372764&lang=en)
- [A 64-year-old patient is post-op day 6 from a small bowel resection. The nurse notes the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=372799&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568941&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._