A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?
Capillary refill time 3 seconds
Sunken anterior fontanel
Weight loss of 5%
Produces tears when crying
The Correct Answer is B
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Rationale:
First, we need to convert the child's weight from pounds to kilograms. We can do this by dividing 55 by 2.2, which gives us 25 kg.
Next, we need to multiply the dose of diphenhydramine by the child's weight to get the total amount of medication needed. We can do this by multiplying 1.25 mg/kg by 25 kg, which gives us 31.25 mg.
Finally, we need to divide the total amount of medication by the concentration of the solution to get the volume to be administered. We can do this by dividing 31.25 mg by 50 mg/mL, which gives us 0.625 mL.
To round the answer to the nearest tenth, we look at the hundredths place and see that it is 5 or more, so we round up the tenths place by one. Therefore, the nurse should administer 0.6 mL of diphenhydramine IV to the child.
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Correct Answer is ["A","B"]
Explanation
Rationale:
A. The MMR vaccine is typically administered at 12 months of age as part of routine immunization schedules.
B. The varicella vaccine is typically administered at 12 months of age as part of routine immunization schedules.
C. Rotavirus (RV): The rotavirus vaccine is typically administered at 2, 4, and 6 months of age.
D. The herpes zoster vaccine is not routinely administered to infants at 12 months of age.
E. The HPV vaccine is typically administered starting at age 11 or 12 years, not at 12 months of age.
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