The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
A. 3 episodes of vomiting in 1 hour.
B. Periodic crying and irritability.
C. Vigorous sucking on a pacifier.
D. No measurable voiding in 4 hours.
Correct Answer: D. No measurable voiding in 4 hours.
The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. Successful management of acute hyperkalemia involves protecting the heart from arrhythmias with the administration of calcium, shifting potassium (K+) into the cells, and enhancing the elimination of K+ from the body.
Option A: Episodes of vomiting should be reported, but it is not the priority and is currently being managed with intravenous infusions. Once clinically significant dehydration is present, effective and safe strategies for rehydration are required. Additionally, following rehydration there may be a risk of recurrence of dehydration and appropriate fluid management may reduce the likelihood of that event.
Option B: Crying and irritability is a normal reaction of an infant who is unwell.
Option C: Vigorous sucking is a good sign in an infant who has episodes of vomiting.