A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply.)
A) Specific gravity of 1.022
B) Respiratory rate of 40 breaths/min
C) Urine output less than 2 ml/kg/hr
D) Heart rate of 135 beats/min
E) Abdominal skin temperature of 96.9°F
A, C
Feedback:
An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min, and abdominal skin temperature of 96.9°F are all within normal limits and do not suggest inadequate fluid balance.
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