A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information, the nurse documents that the infant has:
Failure to thrive.
Malabsorption syndrome.
Severe dehydration.
Risk for fluid volume deficit.
The Correct Answer is C
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Sitting on a nurse’s lap leaning forward is a position that can be used for postural drainage in infants with cystic fibrosis. This position helps drain secretions from the upper lobes of the lungs.
Choice B rationale
The supine position (lying on the back) is also used for postural drainage to target different areas of the lungs. It is not contraindicated for infants with cystic fibrosis.
Choice C rationale
Sitting on a nurse’s lap leaning backward is another position that can be used for postural drainage. This position helps drain secretions from the lower lobes of the lungs.
Choice D rationale
The Trendelenburg position (lying flat on the back with the feet elevated higher than the head) is contraindicated for infants with cystic fibrosis. This position can increase the risk of gastroesophageal reflux and aspiration, which can worsen respiratory symptoms.
Correct Answer is D
Explanation
ChoiceA rationale
Hypotensionisnotacommonmanifestationofhypoxemiaduringanasthmaattack.
ChoiceB rationale
Dysphagiaisnotacommonmanifestationofhypoxemiaduringanasthmaattack.
ChoiceCrationale
Nauseaisnotacommonmanifestationofhypoxemiaduring anasthmaattack.
ChoiceD rationale
Agitationisacommonmanifestationofhypoxemiaduringanasthmaattack.Hypoxemiacancauserestlessnessandagitationduetothelackof oxygenin thebody.