A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

Anuria

A 7% weight loss from baseline

Нуреrpnea

Lethargy

Answer and Explanation

The Correct Answer is B

A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.

B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.

C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.

D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.

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Correct Answer is A

Explanation

A. Tachycardia: Tachycardia, or an increased heart rate, is a common manifestation of opioid withdrawal. Withdrawal stimulates the sympathetic nervous system, leading to symptoms like tachycardia, sweating, anxiety, and restlessness.

B. Miosis: Miosis, or pinpoint pupils, is associated with opioid intoxication, not withdrawal. During withdrawal, pupils are often dilated (mydriasis) rather than constricted.

C. Hypotension: Hypertension, not hypotension, is more commonly seen during opioid withdrawal due to increased sympathetic nervous system activity. Blood pressure tends to rise rather than fall during withdrawal episodes.

D. Sedation: Sedation is a sign of opioid intoxication rather than withdrawal. Clients experiencing withdrawal are more likely to display agitation, irritability, and insomnia rather than drowsiness or sedation.

A. “I will use a sitz bath at least once a day." B. “I will check the amount of bleeding with every other pad change” C. “I will wash my perineum with mild soap and warm water every other day?” D. “I will change my pad at least three times a day”

Correct Answer is D

Explanation

A. "I will use a sitz bath at least once a day.": Sitz baths should be used more frequently, typically several times a day, to promote perineal healing, relieve discomfort, and reduce swelling after an episiotomy. Limiting it to once daily may not provide adequate relief or hygiene support.

B. "I will check the amount of bleeding with every other pad change": The amount of lochia (postpartum bleeding) should be checked with every pad change, not every other. Monitoring bleeding closely helps detect signs of hemorrhage or infection early, ensuring prompt intervention if abnormalities are found.

C. "I will wash my perineum with mild soap and warm water every other day.": Perineal hygiene should be performed daily, and often multiple times a day, especially after urination or bowel movements. Washing every other day is insufficient and could increase the risk of infection at the episiotomy site.

D. "I will change my pad at least three times a day": Changing the perineal pad at least three times daily, or more often as needed, maintains cleanliness, helps prevent infection, and allows for regular monitoring of lochia and healing. This statement demonstrates good understanding of postpartum perineal care.

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A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

Nursing Test Bank

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