A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and the blood pressure is 68/38. The infant's anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child's parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of 94. Which action would the nurse expect to do immediately?

Administer a bolus of D10W.

Offer the child a bottle of an oral rehydration solution such as Pedialyte.

Administer a bolus of hypertonic saline.

Administer a bolus of normal saline.

Answer and Explanation

The Correct Answer is D

Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.

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Correct Answer is C

Explanation

Choice A reason: Applying a warm, moist pack is not the most appropriate action as it may increase swelling and does not address the underlying cause of the edema.

Choice B reason: While it is important to report significant changes to the healthcare provider, mild edema post-surgery can be expected and managed with elevation.

Choice C reason: Elevating the legs on pillows can help reduce edema by promoting venous return and decreasing swelling.

Choice D reason: Encouraging movement of the toes is beneficial for circulation and preventing stiffness, but it is not the primary intervention for edema. Elevation is more effective in this scenario.

A. Place the infant flat and prone. B. Wrap the infant in a warm blanket and allow the father to hold the infant briefly. C. Cover the defect with warm, moist gauze and plastic. D. Encourage breastfeeding to promote maternal bonding.

Correct Answer is C

Explanation

Choice A reason: Placing the infant flat and prone is not the first priority in the care of an infant with gastroschisis.
Choice B reason: While providing warmth and promoting bonding are important, they are not the immediate priority upon admission for an infant with gastroschisis.
Choice C reason: This is the correct choice. The exposed abdominal organs in gastroschisis must be protected immediately to prevent heat and fluid loss and to reduce the risk of infection.
Choice D reason: Breastfeeding is important for bonding and nutrition but is not the first intervention for an infant with gastroschisis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?

Correct Answer is C

Explanation

An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

Correct Answer is C

Explanation

Which statement by the parent indicates a need for further teaching regarding clubfoot?

Which response by the nurse is the most appropriate when parents of a client recently diagnosed with Down syndrome express guilt about causing the condition?

What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

At which stage of development are children able to understand the permanence of death?

What notable sign most likely indicates increased intracranial pressure in an infant?

Which of the following is the best indicator of brain function in a child with a moderate brain injury?

The nurse is preparing an older client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed?

A group of children on one hospital unit are all suffering from separation anxiety. Which child is experiencing the "despair" stage of separation anxiety?