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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. 6 months: At this age, infants typically coo and babble but do not form words.
B. 10 months: Infants might say "mama" or "dada," but their vocabulary is usually less than 10 words.
C. 18 months: By 18 months, most children have a vocabulary of approximately 10–20 words.
D. 24 months: By 24 months, children typically have a vocabulary of about 50 words or more and begin forming two-word phrases.

A. Apply a transparent dressing to the site after the venipuncture. B. Apply a cold compress to the site prior to obtaining the sample. C. Perform an Allen test prior to obtaining the blood sample. D. Obtain the sample using venipuncture.

Correct Answer is D

Explanation

A. Apply a transparent dressing to the site after the venipuncture. A pressure dressing is more appropriate to control bleeding in a child with hemophilia.
B. Apply a cold compress to the site prior to obtaining the sample. Cold compresses reduce swelling but are not required prior to venipuncture.
C. Perform an Allen test prior to obtaining the blood sample. An Allen test is used to evaluate arterial circulation before arterial blood sampling, not for venipuncture.
D. Obtain the sample using venipuncture. Venipuncture is preferred over heel sticks or finger pricks for children with hemophilia because it minimizes trauma and bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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