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:
"Consume 1,500 to 1,700 calories per day." This statement provides a specific calorie range suitable for most adolescents. It ensures they receive adequate energy to support their growth and daily activities. Adequate caloric intake is essential during adolescence to support proper physical and mental development.
Choice B rationale:
"Decrease your vitamin D intake once you start to menstruate." Menstruation does not affect the need for vitamin D intake. In fact, vitamin D is crucial for bone health, especially during adolescence when bones are still developing. Adolescents, including females, should maintain an appropriate level of vitamin D intake to support bone health and overall well-being.
Choice C rationale:
"Increase the amount of your dietary iron intake." During adolescence, especially for females, iron requirements increase due to menstrual losses. Iron is essential for the production of red blood cells and to prevent anemia. Adolescents, particularly females, should be educated about the importance of including iron-rich foods in their diet to meet their increased nutritional needs.
Choice D rationale:
"Limit your sodium intake to 3,000 milligrams per day." While limiting sodium intake is generally advisable for overall health, this statement does not specifically address the nutritional needs of adolescents. Adolescents need guidance on various aspects of nutrition, but limiting sodium intake should be part of a broader discussion about a balanced diet, rather than a singular focus during this educational session.
Correct Answer is C
Explanation
Choice A rationale:
A blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child. While assessing vital signs, the nurse should consider the patient's age-specific parameters. In this case, the blood pressure is not indicative of hemorrhage.
Choice B rationale:
Flushing of the face might be a common postoperative finding and is not necessarily indicative of hemorrhage. It can be caused by various factors such as anesthesia or emotional states. Flushing alone is not a reliable sign of hemorrhage and should be assessed in conjunction with other symptoms.
Choice C rationale:
Continuous swallowing, especially with an increased heart rate and signs of restlessness, can be indicative of hemorrhage after a tonsillectomy and adenoidectomy. Frequent swallowing suggests the presence of blood in the mouth or throat, indicating possible bleeding at the surgical site. This finding requires immediate attention and intervention by the nurse.
Choice D rationale:
A heart rate of 54/min is below the normal range for a 5-year-old child, which typically ranges from 70 to 120 beats per minute. While bradycardia can be a concern, the more specific and immediate indication of hemorrhage in this case is continuous swallowing, which signals active bleeding from the surgical site.
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