A nurse is assessing an infant who has severe dehydration due to gastroenteritis.
Which of the following findings should the nurse expect?
Hypertension.
Increased urine output.
Capillary refill of 2 seconds.
Increased respiratory rate.
Increased respiratory rate.
The Correct Answer is D
An increased respiratory rate is a sign of severe dehydration in infants.
Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.
Choice A is wrong because hypertension is not a sign of severe dehydration in infants.
Choice B is wrong because increased urine output is not a sign of severe dehydration in infants.
In fact, decreased urine output is a sign of dehydration 2.
Choice C is wrong because a capillary refill of 2 seconds is normal and not a sign of severe dehydration in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An allergy to neomycin is a contraindication for receiving the MMR vaccine.
Choice Bis wrong because a family history of seizures is not a contraindication for receiving the MMR vaccine.
Choice Cis wrong because an upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine.
Choice Dis wrong because a temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine.
Correct Answer is B
Explanation
This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
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