A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.
Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Blood pressure.

Respiratory rate.

Body weight.

Skin integrity.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale

Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.

Choice B rationale

Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.

Choice C rationale

Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.

Choice D rationale

Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale

Mummy restraints, also known as swaddling, involve wrapping the infant’s body in a blanket to restrict movement. While this method can be used to calm and secure infants during certain procedures, it is not appropriate for postoperative care following cleft lip and palate repair.

Mummy restraints do not prevent the infant from touching the surgical site and may cause discomfort.

Choice B rationale

Elbow restraints are the appropriate choice for an infant postoperative following cleft lip and palate repair. These restraints prevent the infant from bending their arms and touching or damaging the surgical site. Elbow restraints allow for some movement and circulation while ensuring the surgical area remains protected during the healing process. They are commonly used in pediatric postoperative care to prevent self-injury.

Choice C rationale

Jacket restraints involve securing the infant’s torso to prevent movement. While jacket restraints can be used in certain situations to ensure safety, they are not suitable for postoperative care following cleft lip and palate repair. Jacket restraints do not specifically prevent the infant from touching the surgical site and may cause unnecessary restriction and discomfort.

Choice D rationale

Wrist restraints involve securing the infant’s wrists to prevent movement. While wrist restraints can be used to prevent self-injury, they are not the best choice for postoperative care following cleft lip and palate repair. Wrist restraints may not effectively prevent the infant from reaching the surgical site and can cause discomfort and distress. .

A. BP 90/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38°C (100.4°F). B. BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6°C (99.7°F). C. BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7°C (98.1°F). D. BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F). . .

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.

Choice B rationale

While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.

Choice C rationale

The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.

Choice D rationale

The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .

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A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The provider prescribes restraints.The nurse should apply which of the following types of restraints for this infant?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.
Which of the following should the nurse recognize as the most reliable indicator of fluid loss?