A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor?
Bulging fontanel
Weight loss
Distended jugular vein
Bradycardia
The Correct Answer is B
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
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Related Questions
Correct Answer is C
Explanation
A. Assault: Assault involves the threat or attempt to cause harm that makes the client fear imminent injury. Hiding the client’s car keys does not involve a threat or intimidation, so it does not meet the criteria for assault.
B. Negligence: Negligence involves failing to provide the standard of care, resulting in harm. While hiding the keys is inappropriate, it is an intentional act rather than a failure to act, so it is not classified as negligence.
C. False imprisonment: False imprisonment occurs when a person is intentionally restrained or confined without legal authority or consent. By hiding the client’s car keys to prevent them from leaving, the AP is restricting the client’s freedom of movement, fulfilling the criteria for false imprisonment.
D. Battery: Battery involves intentional physical contact that is harmful or offensive. Hiding car keys does not involve direct physical contact with the client, so it does not constitute battery.
Correct Answer is D
Explanation
A. Administer oxygen via nasal cannula at 2 L/min: Oxygen may support maternal and fetal oxygenation, but it does not treat the underlying cause of hypotension following spinal anesthesia. It is a supportive measure, not the first-line intervention.
B. Place the client in a knee-chest position: This position is not recommended for treating hypotension due to spinal anesthesia. The priority is to improve perfusion through fluid resuscitation and positioning that enhances venous return, such as left lateral tilt.
C. Assist the client to the bathroom: Ambulation is unsafe for a client experiencing hypotension after spinal anesthesia and could worsen hypotension or cause falls. The client should remain supine or in a safe position until blood pressure is stabilized.
D. Give 500 mL bolus of lactated Ringer's: Administering a rapid IV fluid bolus is the first-line intervention for hypotension related to spinal anesthesia. It increases intravascular volume, improves venous return, and helps restore blood pressure to maintain maternal and fetal perfusion.
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