A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.
The child weighs 33 lb.
Which of the following actions should the nurse take?
A.
Notify the provider.
B.
Continue to monitor the client.
C.
Perform a bladder scan at the bedside.
D.
Provide oral rehydration fluids.
The Correct Answer and Explanation is:
The correct answer is B. Continue to monitor the client.
Explanation:
In this scenario, the nurse is assessing a 3-year-old child who has produced 160 mL of urine over the past 8 hours. To determine the appropriate course of action, it’s essential to understand the normal urine output for a child of this age and consider the context of their overall health and fluid status.
Normal Urine Output for a Child: For a child of this age, normal urine output is typically around 1 to 2 mL/kg/hour. To convert the child’s weight into kilograms: 33 lb×1 kg2.2 lb≈15 kg33 \text{ lb} \times \frac{1 \text{ kg}}{2.2 \text{ lb}} \approx 15 \text{ kg}33 lb×2.2 lb1 kg≈15 kg
Using the normal urine output range: 1 mL/kg/hour×15 kg=15 mL/hour1 \text{ mL/kg/hour} \times 15 \text{ kg} = 15 \text{ mL/hour}1 mL/kg/hour×15 kg=15 mL/hour 2 mL/kg/hour×15 kg=30 mL/hour2 \text{ mL/kg/hour} \times 15 \text{ kg} = 30 \text{ mL/hour}2 mL/kg/hour×15 kg=30 mL/hour
Therefore, the expected urine output over 8 hours should be between: 15 mL/hour×8 hours=120 mL15 \text{ mL/hour} \times 8 \text{ hours} = 120 \text{ mL}15 mL/hour×8 hours=120 mL 30 mL/hour×8 hours=240 mL30 \text{ mL/hour} \times 8 \text{ hours} = 240 \text{ mL}30 mL/hour×8 hours=240 mL
Given the child has produced 160 mL of urine over 8 hours, their output falls within the lower end of the expected range. This suggests that while the urine output is on the lower side, it is not necessarily abnormal.
Actions and Rationale:
- Notify the Provider (Option A): This step might be considered if the urine output were significantly lower or if there were other symptoms suggesting acute kidney injury or dehydration. However, given the output is just slightly lower than expected, immediate notification might not be necessary unless accompanied by other symptoms.
- Continue to Monitor the Client (Option B): This is the most appropriate action in this case. Monitoring allows for ongoing assessment of the child’s urine output and overall condition. If there are no other signs of dehydration or distress, continuing to monitor and reassessing the urine output periodically is appropriate.
- Perform a Bladder Scan at the Bedside (Option C): A bladder scan is generally performed if there are concerns about urinary retention or difficulty with urination. Given that the child’s output is not extremely low and there are no specific symptoms indicating retention, this may not be the immediate next step.
- Provide Oral Rehydration Fluids (Option D): While rehydration could be beneficial if dehydration were suspected, there is no current indication of dehydration based solely on the urine output. Rehydration should be considered if additional signs of fluid imbalance or dehydration are present.
In conclusion, continuing to monitor the client is the most appropriate action as it allows the nurse to assess the child’s urine output over time and identify any trends or changes that might require further intervention.