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 D
Explanation
Choice A rationale:
Discouraging the parents from allowing siblings to view the body can prevent healthy grieving and closure for the siblings. Allowing siblings to view the body, if they wish, can help them understand the reality of the situation and cope with their emotions in a healthy way.
Choice B rationale:
Providing a follow-up phone call 1 week following the infant's death is a good practice, but it is not the most immediate and crucial action in this situation. Acknowledging the family's feelings of guilt and providing emotional support should take precedence.
Choice C rationale:
Avoiding discussing details of the attempt to revive the infant might hinder the family's ability to process the situation. Open communication, including discussing the events leading to the infant's death, can help the family members come to terms with their loss.
Choice D rationale:
Acknowledging the family members' feelings of guilt is the correct choice. Parents and family members often experience guilt after the death of an infant from SIDS, wondering if there was something they could have done differently. The nurse should acknowledge these feelings and provide reassurance, emphasizing that SIDS is not the result of parental actions or negligence.
Correct Answer is B
Explanation
Choice A rationale:
Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.
Choice B rationale:
Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.
Choice C rationale:
Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.
Choice D rationale:
Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.
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