A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Bulging anterior fontanel
Decreased temperature
Hypertension
Oliguria
The Correct Answer is D
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Place a warm, wet washcloth over your child's forehead and the bridge of their nose." Warm compresses may actually dilate blood vessels, which can worsen the bleeding. Cold compresses are preferred to help constrict vessels.
B. "Use your thumb and forefinger to apply pressure to the sides of your child's nose." This is the correct first-aid measure for epistaxis. The parent should pinch the soft part of the nose continuously for 10–15 minutes while the child leans forward.
C. "Have your child lie down and turn their head to the side for 10 minutes." Lying down can increase blood flow to the nose and may cause blood to be swallowed, which can lead to nausea or vomiting.
D. “Tell your child to blow their nose gently, and then sit down and tilt their head backward." Tilting the head back can cause blood to drain into the throat, increasing the risk of aspiration and stomach upset. Leaning forward is the proper position.
Correct Answer is B
Explanation
A. Premature atrial complexes. These are early electrical impulses originating in the atria that cause premature heartbeats, but they do not consistently lengthen the P-R interval. The P-R interval usually remains within normal limits unless another condition is present.
B. First-degree atrioventricular (AV) block. A constant P-R interval longer than 0.20 seconds (normal range: 0.12–0.20 seconds) is characteristic of a first-degree AV block. A P-R interval of 0.35 seconds indicates a prolonged conduction delay through the AV node, consistent with this dysrhythmia.
C. Complete heart block. In complete (third-degree) heart block, there is no consistent relationship between P waves and QRS complexes, and the P-R interval is not constant. This is not consistent with a stable, prolonged P-R interval.
D. Atrial fibrillation. Atrial fibrillation is marked by irregularly irregular rhythm and absent, unidentifiable P waves, not a consistent P-R interval. The atria are quivering, not contracting in a coordinated way.
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