A nurse is caring for an infant who weighs 7.8 kg (17.2 lb) and was admitted yesterday for treatment of moderate dehydration. Which of the following findings indicates to the nurse that the infant's condition is improving?
Respiratory rate 70/min
Capillary refill is greater than 3 seconds.
Dry mucous membranes
Fontanelle is level and soft.
The Correct Answer is D
A. Respiratory rate 70/min: A respiratory rate of 70/min is high for an infant and may indicate ongoing respiratory distress or other issues. Normal respiratory rates for infants are generally 30-60 breaths per minute. This does not indicate improvement.
B. Capillary refill is greater than 3 seconds. Capillary refill time greater than 3 seconds indicates poor perfusion, which can be a sign of continued dehydration or shock. This does not indicate improvement.
C. Dry mucous membranes: Dry mucous membranes are a sign of dehydration. For an infant's condition to be improving, mucous membranes should be moist.
D. Fontanelle is level and soft. A level and soft fontanelle indicates that the infant is likely well-hydrated. Sunken fontanelles are a sign of dehydration, so this finding suggests improvement in the infant’s hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ask another nurse to confirm the toddler's identity. While involving another nurse might add a layer of verification, it is not the primary or standard method of ensuring patient identity.
B. Check the toddler's ID band against the medical record. This is the standard and safest method for verifying a patient's identity. The ID band provides reliable information that can be cross-referenced with the medical record.
C. Check the toddler's room number against their ID band. Room numbers can change and are not a reliable method for identifying patients. The ID band should be used directly for verification.
D. Ask the parent to confirm the toddler's identity. While parents are generally reliable, the most secure and recommended practice is to use the ID band to verify identity directly against the medical record
Correct Answer is C
Explanation
A. The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
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