A nurse is assessing an infant who has severe dehydration due to gastroenteritis.
Which of the following findings should the nurse expect?
A.
Hypertension.
B.
Increased urine output.
C.
Capillary refill of 2 seconds.
D.
Increased respiratory rate.
E.
Increased respiratory rate.
The Correct answer and Explanation is:
The correct answer is:
D. Increased respiratory rate.
Explanation:
Severe dehydration in infants, particularly due to gastroenteritis, results in the loss of significant amounts of fluids and electrolytes, which can cause a range of systemic effects. The body compensates for this fluid loss in various ways, leading to several observable clinical signs and symptoms.
Increased Respiratory Rate (Tachypnea):
When an infant is severely dehydrated, the body responds by attempting to maintain oxygen delivery and metabolic balance. One of the body’s compensatory mechanisms is to increase the respiratory rate. This occurs because dehydration can cause metabolic acidosis, where the blood becomes more acidic due to the buildup of waste products. To correct this, the respiratory system increases the breathing rate to expel more carbon dioxide (CO2) and reduce the acid levels in the blood. Increased respiratory effort is also related to reduced circulating blood volume (hypovolemia), which affects oxygenation and necessitates an increase in respiratory rate to improve oxygen delivery.
Incorrect Options:
- A. Hypertension: This is incorrect. Dehydration leads to a decreased circulating blood volume, which typically results in hypotension (low blood pressure) rather than hypertension (high blood pressure). As the body loses fluid, it becomes harder to maintain normal blood pressure.
- B. Increased Urine Output: This is incorrect. In severe dehydration, urine output typically decreases significantly (oliguria or anuria) as the kidneys attempt to conserve fluid to maintain blood volume and electrolyte balance.
- C. Capillary Refill of 2 Seconds: This is incorrect. In severe dehydration, capillary refill time is usually delayed, taking longer than 2 seconds due to decreased perfusion from reduced blood volume. A capillary refill time of 2 seconds is considered normal.
Overall, the increased respiratory rate in a severely dehydrated infant is a critical compensatory response to address metabolic disturbances caused by fluid and electrolyte loss.