A triage nurse receives a call from the mother of an infant who appears pale, is "breathing fast," and appears sleepy while feeding. What data would the nurse need to gather next?
1. Newborn's daily iron intake
2. Number of wet diapers a day
3. Skin color
4. Bilirubin level
1
Rationale 1: A newborn who appears pale, appear sleepy or tires easily while feeding, and is tachycardic or tachypneic at rest could be deficient in iron.
Rationale 2: The number of wet diapers a day would provide information concerning hydration.
Rationale 3: Skin color would provide information about jaundice.
Rationale 4: Bilirubin level would provide information about jaundice.
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