Pediatric nursing · practice question
A 2-year-old toddler in the emergency department is being evaluated for routine childhood immunizations. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which finding requires the nurse to intervene immediately?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
B. The new finding that capillary refill 4 seconds with dry mucous membranes and sunken fontanelle.
Why
Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
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