A nurse is caring for an 8-month-old child admitted with dehydration. Which of the following client findings indicates that oral rehydration therapy has been effective? (Select all that apply)
Specific gravity of 1.010
Moist mucous membranes
Capillary refill less than 3 seconds
Sunken anterior fontanelle
Heart rate of 146/min
Correct Answer : A
Choice A reason:
A specific gravity of 1.010 indicates that the child’s urine is adequately diluted, suggesting proper hydration. Normal urine specific gravity ranges from 1.005 to 1.030. A value of 1.010 falls within this range and indicates that the kidneys are functioning well and the child is not dehydrated.
Choice B reason:
Moist mucous membranes are a sign of adequate hydration. When a child is well-hydrated, the mucous membranes in the mouth and other areas remain moist. This is a positive indicator that oral rehydration therapy has been effective in restoring the child’s fluid balance.
Choice C reason:
Capillary refill time of less than 3 seconds is another indicator of proper hydration and good peripheral perfusion. This means that the blood is circulating well throughout the body, and the tissues are receiving adequate oxygen and nutrients. A capillary refill time of less than 3 seconds is considered normal and suggests effective rehydration.
Choice D reason:
A sunken anterior fontanelle is a sign of dehydration in infants. When the fontanelle is sunken, it indicates that the child has lost a significant amount of fluid. Therefore, this finding does not indicate that oral rehydration therapy has been effective. Instead, it suggests that the child may still be dehydrated.
Choice E reason:
A heart rate of 146/min is elevated for an 8-month-old child1. Normal heart rates for infants range from 80 to 160 beats per minute. While this heart rate is within the upper limit of normal, it can also be a sign of dehydration or other stressors. Therefore, it is not a definitive indicator of effective rehydration therapy.
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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Peanuts are not recommended for infants, especially those under one year of age, due to the risk of choking and potential allergies. Additionally, peanuts are not a significant source of iron and would not be effective in preventing iron deficiency anemia in infants. Therefore, this choice is not appropriate for preventing iron deficiency anemia in a 6-month-old infant.
Choice B reason:
Iron (ferrous sulfate) tablets are not typically recommended for infants unless prescribed by a healthcare provider. Infants who are exclusively breastfed or partially breastfed should receive iron supplementation starting at 4-6 months of age, but this is usually in the form of liquid drops rather than tablets. It is important to follow the guidance of a healthcare provider when administering iron supplements to infants.
Choice C reason:
Sautéed liver is a rich source of iron, but it is not suitable for a 6-month-old infant. Introducing solid foods to infants should be done gradually, starting with iron-fortified cereals and pureed fruits and vegetables. Liver can be introduced later as part of a balanced diet, but it is not the first choice for preventing iron deficiency anemia in a young infant.
Choice D reason:
Iron-fortified baby cereal is the recommended choice for preventing iron deficiency anemia in a 6-month-old infant who is still breastfeeding. These cereals are specifically designed to provide the necessary iron that infants need as they transition to solid foods. Starting with iron-fortified cereals helps ensure that the infant receives adequate iron to support healthy growth and development.
Correct Answer is D
Explanation
Choice A reason:
Releasing traction every hour to perform skin care: Releasing traction every hour is not recommended as it can disrupt the alignment and healing process of the fractured femur. Skin care is important, but it should be performed without compromising the traction setup.
Choice B Reason:
Releasing traction once every 8 hours to check circulation: While checking circulation is crucial, releasing traction every 8 hours is not necessary and can interfere with the therapeutic benefits of traction. Circulation can be monitored without releasing the traction.
Choice C Reason:
Maintaining continuous traction until 1 hour before the scheduled surgery: Continuous traction is essential to maintain the alignment of the fractured femur. However, there is no need to release traction 1 hour before surgery unless specifically instructed by the surgical team.
Choice D Reason:
Maintaining continuous traction and checking the position of traction: This is the most appropriate action. Continuous traction ensures proper alignment and healing of the fractured femur. Regularly checking the position of traction helps prevent complications and ensures the effectiveness of the treatment.
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