A 3-week-old is brought in with fussiness and spitting up. What should be the priority for the nurse?

In the scenario where a 3-week-old infant presents with fussiness and spitting up, the priority for the nurse is to identify the type of formula the caregiver uses. Understanding the specific formula allows the nurse to assess its potential contributions to the infant's symptoms, such as spitting up and fussiness, which could indicate issues like gastroesophageal reflux or intolerance to certain components in the formula.

Knowing the type of formula can assist in determining whether dietary modifications are needed to alleviate the symptoms. For example, some infants may be sensitive to cow's milk protein or lactose, which could lead to gastrointestinal distress. Gathering this information early in the assessment guides further evaluation and interventions, ensuring that the infant's dietary needs are aligned with their health status.

While performing a physical examination, assessing for signs of dehydration, and starting intravenous rehydration are all important components of pediatric nursing care, they may not be the immediate priority when the presenting symptoms could be directly related to a dietary issue. Identifying the formula type is foundational as it can inform subsequent steps in the management of the infant's condition.