A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.
The child weighs 33 lb.
Which of the following actions should the nurse take?
Notify the provider.
Continue to monitor the client.
Perform a bladder scan at the bedside.
Provide oral rehydration fluids.
The Correct Answer is B
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a.Talcum powder is not recommended for use with infants because it can be inhaled, potentially causing respiratory problems. Instead, a barrier cream or ointment (such as zinc oxide or petroleum jelly) should be used to protect the skin from moisture and irritants.
b.While cloth diapers can be less irritating than some disposable diapers, they may not be as effective at keeping the skin dry. The priority is to keep the area dry and clean, regardless of the type of diaper used. Super-absorbent disposable diapers are often recommended because they can help keep the skin dry.
c.Exposing the skin to hot air can cause burns and further irritation. Instead, allowing the skin to air dry naturally (without the use of hot air) during diaper changes can be beneficial.
d.A moisturizer creates a barrier between the skin and irritants like urine and stool.Wiping with a moisturizer can minimize friction during cleaning, which can be uncomfortable for the baby and further irritate the skin.Some moisturizers can help soothe and hydrate the inflamed skin, promoting healing.
Correct Answer is ["A","B","C","D","E"]
Explanation
The nurse should include all of these points in the teaching.
A. Avoiding bubble baths can help prevent irritation and infection.
B. Watching for manifestations of infection can help detect any worsening or recurrence of the infection.
C. Emptying the bladder completely with each void can help prevent urine from remaining in the bladder and causing infection.
D. Wiping the perineal area front to back can help prevent bacteria from
spreading to the urethra.
E. Wearing cotton underpants can help keep the area dry and reduce the risk of infection.

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