A nurse is caring for a 6-month-old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?
Capillary refill greater than 4 seconds
Bradycardia
Tachypnea
Lethargy
The Correct Answer is C
A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Feed infant in a supine position: Contraindicated
- Supine feeding increases the risk of aspiration and exacerbates reflux.
Offer smaller, more frequent feedings: Appropriate
- Smaller, frequent feedings reduce gastric distension and reflux episodes.
Thicken formula feedings with rice cereal: Appropriate
- Thickened feedings can help reduce reflux by increasing the weight of the stomach contents.
Place infant in a side-lying position for sleep: Contraindicated
- The recommended sleep position for infants is supine (on the back) to reduce the risk of sudden infant death syndrome (SIDS).
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