Case Study 3.docx - Samantha Hedges NURS 458 Two-month-old...

Samantha Hedges
NURS 458
Two-month-old Kyla is brought is brought to the pediatrician’s office for a well-child check
by her mother, Sierra. Sierra is a 17-year-old mother who lives with her current boyfriend,
who is not Kyla's father. Sierra works at a local gas station 6 days a week and her boyfriend
watches the baby. Upon assessment it is noted that Kyla's weight has dropped from the
56
th
percentile to the 35
th
percentile since her last well child check. The infant appears thin and
lethargic. Her anterior fontanel is sunken, she cries without tears, and Sierra reports only two
wet diapers in the last 24 hours. When asked to demonstrate how she mixes formula, Sierra
relays to the nurse that she uses double the amount of water than recommended on the
formula label and is keeping Kyla on a strict Q6 hour feeding schedule so she "doesn't go
through formula so fast because it is expensive."
1. What is your nursing assessment priority and primary concern for this patient
situation?