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.
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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 B
Explanation
A. Encourage maintaining bilateral elbow restraints: This is not typically used for cleft palate repair. Elbow restraints might be used for other procedures.
B. Apply antibiotic ointment to the suture line for 3 days postoperatively: Applying antibiotic ointment to the suture line helps prevent infection and promotes healing. It’s essential to follow the postoperative care instructions to ensure the best outcomes for the infant.
C. Encourage use of straws when drinking fluids: Using straws can create negative pressure in the oral cavity, which may put stress on the suture line and compromise wound healing. The suction force generated during straw use can potentially disrupt the surgical site.
D. Avoid disturbing any crusts that form on the suture line: This is generally good advice to promote healing and prevent infection.
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