The nurse working in a pediatrician's office receives a call from the mother of a 4-month-old infant reporting that the child has vomited the entire feeding twice and has had four diarrhea stools since awakening at 4 a.m
The nurse first asks the mother: 1. "How much formula are you feeding at one time?"
2. "What type of formula are you using?"
3. "When was the last wet diaper you changed?"
4. "What color is the emesis?"
3
Rationale: While all of these questions are valid assessment data to be collected, the most important assessment is the child's condition before attempting to determine cause of the problem, so the nurse should first address the child's condition by determining when she last voided, as an indicator of possible dehydration.
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