A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin. Which of the following findings indicates moderate dehydration?
Decreased respiratory rate
Bulging anterior fontanel
Mottled skin
Capillary refill 3 seconds
The Correct Answer is D
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
Correct Answer is A
Explanation
A. "Share a bedroom with your infant for the first 6 months." The American Academy of Pediatrics (AAP) recommends room-sharing (but not bed-sharing) for at least the first 6 months to reduce the risk of SUID/SIDS.
B. "Place your infant on a soft crib mattress after they are 4 months old." A firm mattress is always recommended, as soft bedding increases the risk of suffocation and SUID/SIDS.
C. "Cover your infant with a nonflammable blanket at bedtime." Blankets should not be used, as they pose a suffocation risk. Instead, parents should use a sleep sack or wearable blanket for warmth.
D. "Use bumper pads around the interior of your infant's crib." Bumper pads increase the risk of suffocation and entrapment and are not recommended for safe sleep.
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