A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Pale and a 24-hr fluid deficit of 30 mL

Decreased appetite and irritability

Temperature 38° C (100.4° F) and pulse rate 124/min

Sunken fontanels and dry mucous membranes

Answer and Explanation

The Correct Answer is D

A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.

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

Explanation

A. Placenta Previa: Placenta previa causes painless, bright red vaginal bleeding, not back pain or contractions. The cervix is 2 cm dilated, which suggests the bleeding is due to labor progression, not previa.
B. Preterm Prelabor Rupture of Membranes (PROM): The client is 33 weeks pregnant and has lower back pain, pinkish vaginal discharge, regular contractions, these signs suggest preterm labor, which can be associated with PROM. History of preterm birth (30 weeks gestation) increases her risk for another preterm complication.
C. Seizures: No neurological symptoms (e.g., headache, visual changes) to indicate risk for seizures or eclampsia.
D. Sepsis: The client has a fever of 38.4°C (101.1°F), which is concerning for infection. Minimal fetal heart rate (FHR) variability may indicate fetal distress due to infection. Urinalysis was collected, suggesting the provider is evaluating for a urinary tract infection (UTI), which could progress to sepsis. Preterm labor + fever raises suspicion for chorioamnionitis, a major cause of maternal and neonatal sepsis.
E. Disseminated Intravascular Coagulation (DIC): DIC is usually triggered by severe complications like placental abruption, fetal demise, or amniotic fluid embolism, none of which are present here.
F. Preeclampsia: No hypertension (BP is 130/78 mm Hg), no proteinuria or signs of end-organ damage. More common after 20 weeks but less likely with normal BP

A. "Your doctor wouldn't have ordered this treatment unless it was necessary." B. "it's okay to be nervous before this treatment." C. "You don't have to go through with the treatment. D. "Most people who have this procedure feel better following the treatment."

Correct Answer is C

Explanation

A. Incorrect – This statement may pressure the client into proceeding with treatment.
B. Incorrect – While acknowledging nervousness is helpful, it does not address the client’s concern about withdrawing consent.
C. Correct – The client has the right to withdraw consent at any time, and the nurse should support autonomy.
D. Incorrect – This statement is reassuring but does not acknowledge the client’s right to refuse.

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A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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