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 D

Explanation

A. Cover the equipment used in the infant's care prior to the parents' first visit: While this might reduce visual distress, it does not directly support the grieving process or involve the parents in meaningful interactions.
B. Reduce the parents' distress by limiting the duration of their visit: Limiting visit time may increase distress by reducing opportunities for the parents to process emotions.
C. Avoid leaving the parents alone with the infant during their visit: Parents may value privacy to express their feelings and bond with the infant without outside observation.
D. Involve the parents in the infant's caregiving activities during their visit. Involving parents in caregiving helps them feel connected to their child and provides meaningful time to bond, which supports healthy grieving.

A. Bounding peripheral pulses B. Cyanotic spells C. Stridor D. Anemia E. heart murmur

Correct Answer is ["B","E"]

Explanation

A. "Bounding peripheral pulses." Bounding pulses are not characteristic of Tetralogy of Fallot. Instead, pulses may be normal or diminished, depending on the severity of the defect.
B. "Cyanotic spells." Tetralogy of Fallot causes decreased oxygenation, leading to periodic cyanotic episodes, particularly during crying or feeding ("tet spells").
C. "Stridor." Stridor is associated with upper airway obstructions, not cardiac defects like Tetralogy of Fallot.
D. "Anemia." Anemia is not a primary finding in Tetralogy of Fallot. Polycythemia (increased red blood cells) is more common due to chronic hypoxia.
E. "Heart murmur." A systolic murmur is common due to the pulmonary stenosis and ventricular septal defect associated with Tetralogy of Fallot.

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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

A nurse is caring for an infant who sustained critical injuries in a motor vehicle accident and is not expected to survive. Which of the following interventions should the nurse implement to support the infant's parents in anticipatory grieving?

Correct Answer is D

Explanation

A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect? Select all that apply.

Correct Answer is ["B","E"]

Explanation

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