A nurse is assisting with the care of a 2-year-old child.
Click to highlight the findings that indicate the child has progressed. To deselect a finding, click on the finding again.
Day 3, 0900:
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
The Correct Answer is ["A","B","E","F","G"]
Rationale for correct choices:
• Weight: The child’s weight increased from 9.5 kg on day 2 to 10.2 kg on day 3, surpassing the admission weight of 10 kg. This indicates successful rehydration and restoration of fluid balance. Weight gain is a reliable objective marker of improvement in pediatric dehydration.
• Bowel pattern: The child’s stools changed from six watery stools on day 2 to two formed stools on day 3. This reflects resolution of diarrhea and recovery of gastrointestinal function. Normalization of bowel movements indicates that electrolyte and fluid losses have been addressed effectively.
• Urine specific gravity: Urine specific gravity decreased from 1.031 on admission to 1.018 on day 3. This reflects improved hydration status and kidney perfusion, as urine is less concentrated. Monitoring urine concentration helps evaluate the effectiveness of fluid replacement therapy.
• Skin turgor: Skin turgor improved from 2 seconds to less than 1 second and appears consistent with the child’s baseline. This indicates restored hydration and effective fluid therapy. Normal skin turgor demonstrates recovery from extracellular fluid deficit.
• Heart rate: The heart rate decreased from a tachycardic 116/min on Day 2 to 100/min on Day 3. A stable, lower heart rate indicates that the circulatory volume is adequate and the heart no longer needs to overcompensate for low blood volume.
Rationale for incorrect findings:
• Sodium level: Sodium remained within normal range (138 mEq/L), so while stable, it does not specifically indicate improvement beyond baseline.
• Respiratory rate: Respiratory rate remained mildly elevated at 26 breaths/minute; it shows stability but does not directly indicate recovery from dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Wait 5 minutes between doses.": Sublingual nitroglycerin is taken to relieve acute angina episodes. The recommended protocol is to place one tablet under the tongue and, if pain persists, repeat every 5 minutes as needed, up to a maximum of three doses within 15 minutes. Waiting 5 minutes between doses allows the medication to work while monitoring for resolution of symptoms or adverse effects.
B. "Place 2 tablets under your tongue.": Only one tablet should be taken initially. Taking multiple tablets at once increases the risk of severe hypotension, headache, and dizziness. Proper dosing is critical to both effectiveness and safety.
C. "You can take up to 4 tablets in 20 minutes.": The maximum recommended is three tablets in 15 minutes, not four in 20 minutes. Exceeding this can cause significant hypotension and cardiovascular complications.
D. "Drink a full glass of water with the medication.": Sublingual nitroglycerin should not be swallowed or taken with water because it needs to dissolve under the tongue for rapid absorption into the bloodstream. Drinking water would reduce its effectiveness.
Correct Answer is D
Explanation
A. Amniotic fluid color: Assessing amniotic fluid color is important to identify meconium-stained or bloody fluid, which can indicate fetal compromise or infection. While this provides valuable information, it does not provide immediate data about fetal well-being, making it secondary to continuous fetal monitoring.
B. The client's temperature: Maternal temperature is monitored to detect infection, especially after rupture of membranes. However, fever develops over time, so it is not the most immediate priority immediately following amniotomy. Early assessment focuses on detecting acute fetal compromise.
C. Frequency of contractions: Monitoring contraction frequency, duration, and intensity is essential for assessing labor progress. While contraction patterns guide labor management, fetal response to contractions is a higher priority after membrane rupture, as sudden changes can affect fetal oxygenation.
D. Fetal heart rate: Fetal heart rate assessment is the priority immediately after an amniotomy because sudden changes in amniotic fluid volume, umbilical cord prolapse, or cord compression can compromise fetal oxygenation. Early identification of decelerations or abnormal patterns allows rapid intervention to prevent fetal injury.
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