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%.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Providing a high-calorie, low-protein diet is not directly related to the management of osteomyelitis. However, proper nutrition is essential for overall healing and immune function.
Choice B rationale:
Encouraging frequent physical activity to increase bone mass is not appropriate for a child with osteomyelitis. Physical activity can worsen the condition and cause further damage to the affected bone.
Choice C rationale:
Maintaining a patent intravenous catheter is important for administering intravenous antibiotics, which are the mainstay of treatment for osteomyelitis. Ensuring that the catheter is functional and infection-free is crucial for the delivery of appropriate antibiotics to combat the infection.
Choice D rationale:
Initiating contact precautions is not necessary for osteomyelitis. Osteomyelitis is not typically spread through direct contact but results from the spread of bacteria through the bloodstream to the affected bone.
Correct Answer is A
Explanation
Choice A rationale:
Abdominal pain in a postoperative patient, especially after an appendectomy, is concerning and should be reported to the provider immediately. It could indicate complications such as infection, ileus, or surgical site issues. Prompt reporting and assessment are crucial to prevent further complications and ensure the patient's well-being.
Choice B rationale:
Muscle rigidity is not a typical finding 1 hour postoperative following an appendectomy. While muscle rigidity can be a sign of various conditions, it is not a common immediate concern after this type of surgery, especially in the early postoperative period.
Choice C rationale:
A temperature of 36.4°C (97.5°F) is within the normal range for body temperature. While it's important to monitor the patient's temperature for signs of infection, this temperature alone is not a cause for immediate concern.
Choice D rationale:
A heart rate of 63/min is within the normal range for an adolescent at rest. Heart rate can vary based on factors such as age, activity level, and overall health. A heart rate of 63/min does not indicate an immediate problem and is not a cause for immediate concern in this context.
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