A nurse is caring for an infant who has rotavirus.
Which of the following findings indicates that the infant is moderately dehydrated?

Respiratory rate 28/min.

Bradycardia.

Capillary refill 1 second.

Weight loss 7%.

Answer and Explanation

The Correct Answer is D

The correct answer is d. Weight loss 7%.

Choice A reason: Respiratory rate 28/min. The normal respiratory rate for infants can vary depending on their age. For newborns, it’s typically between 30-60 breaths per minute1. As they grow older, the rate decreases. For example, infants aged 0-5 months have a normal respiratory rate of 25-40 breaths per minute. Therefore, a respiratory rate of 28/min falls within the normal range for an infant and does not specifically indicate moderate dehydration.

Choice B reason:. Bradycardia in infants is defined as a heart rate that is slower than normal for their age. For infants aged 0-3 years, a heart rate less than 100 beats per minute is considered bradycardia3. Bradycardia can be a sign of many conditions, including dehydration, but on its own, it is not a definitive indicator of moderate dehydration.

Choice C reason: Capillary refill time is the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. In infants, a normal capillary refill time is less than 2 seconds, and in newborns, it can be up to 3 seconds. A capillary refill time of 1 second is within the normal range and does not indicate moderate dehydration.

Choice D reason: Weight loss 7%. In infants, a weight loss of about 6-9% is generally considered a sign of moderate dehydration. This is because infants are particularly susceptible to fluid loss due to their small body size and higher body water content. A 7% weight loss in an infant who has rotavirus, which can cause significant fluid loss through diarrhea, is a strong indicator of moderate dehydration.

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Correct Answer is C

Explanation

The correct answer is C. Blood pressure 118/74 mm Hg.

Choice A reason: The respiratory rate of 26 breaths per minute is within the normal range for a 2-year-old child, which is typically 20-30 breaths per minute1. Therefore, this finding does not need to be reported to the provider.

Choice B reason: A pulse rate of 98 beats per minute is also within the normal range for a 2-year-old, which is 90-140 beats per minute. This is a typical finding and does not require reporting to the provider.

Choice C reason: The blood pressure reading of 118/74 mm Hg is higher than the normal range for a 2-year-old, which should be approximately 86-106/42-63 mm Hg. This elevated blood pressure should be reported to the provider as it may indicate an underlying health issue.

Choice D reason: A temperature of 37.2°C (99° F) is at the upper limit of the normal range for body temperature in children and is not typically a cause for concern unless there are other signs of illness1. This temperature does not need to be reported to the provider.

A. Teach the child about cast care. B. Petal the edges of the cast. C. Administer pain medication. D. Elevate the child's leg.

Correct Answer is D

Explanation

Choice A rationale:

Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.

Choice B rationale:

Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.

Choice C rationale:

Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.

Choice D rationale:

Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.

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A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

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A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

A nurse is caring for an infant who has rotavirus.
Which of the following findings indicates that the infant is moderately dehydrated?