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 B
Explanation
Choice A rationale:
Feeding the infant a specific volume of formula is not the priority when caring for a child with a cleft of the soft palate. Infants with cleft palate may have difficulty creating suction during feeding, which can lead to inefficient feeding and inadequate intake. It is essential to focus on proper feeding techniques rather than a specific volume.
Choice B rationale:
Elevating the infant's head to a 10° angle during feedings is the correct action. This positioning helps prevent formula or breast milk from flowing into the nasal cavity, reducing the risk of aspiration. Aspiration can lead to respiratory issues and other complications. Elevating the head facilitates swallowing and reduces the risk of choking.
Choice C rationale:
Discontinuing a feeding if the infant's eyes become watery is not a valid indication to stop feeding. Watery eyes are not directly related to feeding difficulties in infants with a cleft palate. It is essential to assess the infant's overall feeding performance and address specific issues such as inadequate suction or swallowing difficulties.
Choice D rationale:
Postponing burping until after completing each feeding is not appropriate. Burping should be done periodically during feedings to prevent the accumulation of air in the infant's stomach, which can cause discomfort and contribute to reflux. Burping helps release trapped air and promotes comfortable feeding experiences for the infant.
Correct Answer is D
Explanation
Choice A rationale:
An increase in venous pressure is not an indication that furosemide, a loop diuretic, is effective. In fact, increased venous pressure could suggest worsening heart failure. Loop diuretics like furosemide work by promoting the excretion of excess fluid and sodium from the body, leading to a decrease in blood volume and relieving symptoms of heart failure, such as peripheral edema and pulmonary congestion.
Choice B rationale:
A decrease in cardiac output is not the desired effect of furosemide. Furosemide helps reduce fluid overload and congestion in the heart and lungs, ultimately improving cardiac output. If cardiac output decreases, it indicates that the medication might not be effective or the heart failure is worsening.
Choice C rationale:
An increase in potassium levels is not directly related to the effectiveness of furosemide. Furosemide can cause potassium depletion as it increases the excretion of potassium in the urine. Monitoring potassium levels is essential because severe hypokalemia can lead to cardiac arrhythmias. However, the absence of an increase in potassium levels does not indicate furosemide's effectiveness.
Choice D rationale:
A decrease in peripheral edema is the desired effect of furosemide. By reducing fluid retention, furosemide helps decrease peripheral edema, which is a common symptom of heart failure. The nurse should assess the child for a decrease in peripheral edema to determine the medication's effectiveness. Monitoring daily weights and assessing for reduced edema are key indicators of furosemide's efficacy.
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