A nurse is assessing an infant with suspected gastroenteritis. Which assessment finding should be reported immediately?
Dry lips and sunken fontanelle
Slightly decreased urine output
Mild irritability during feedings
Occasional vomiting after feeds
The Correct Answer is A
A) Correct. Dry lips and a sunken fontanelle are signs of severe dehydration in an infant and require immediate attention.
B) Incorrect. While decreased urine output is a concern, it may not necessitate immediate reporting if it is only slightly decreased.
C) Incorrect. Mild irritability during feedings is a symptom of discomfort but may not necessitate immediate reporting.
D) Incorrect. Occasional vomiting after feeds is a common symptom of gastroenteritis and may not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Severe viral gastroenteritis can lead to malnutrition due to the inability to absorb nutrients properly during the acute phase.
B) Incorrect. Hypernatremia, or high sodium levels, is not a common complication of gastroenteritis.
C) Incorrect. Hypotension, or low blood pressure, may occur in severe cases, but it is not a typical complication during recovery.
D) Incorrect. Urinary retention is not a typical complication of gastroenteritis.
Correct Answer is B
Explanation
A) Incorrect. Being symptom-free for only 24 hours may not be sufficient to ensure full recovery from gastroenteritis.
B) Correct. It is important to wait until all symptoms, including diarrhea, vomiting, and abdominal pain, have completely resolved before returning to work to prevent the spread of infection.
C) Incorrect. Returning to work when only feeling slightly better may risk spreading the infection to others.
D) Incorrect. 48 hours of symptom improvement may not be sufficient to ensure full recovery from gastroenteritis. It is important to wait until all symptoms have completely resolved.
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