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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Correct Answer is C
Explanation
Choice A rationale
Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.
Choice B rationale
Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.
Choice C rationale
Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.
Choice D rationale
Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.
Correct Answer is C
Explanation
Choice A rationale
Auscultating for a cardiac murmur can be helpful but is not the most specific assessment for coarctation of the aorta. Murmurs can be present in various cardiac conditions.
Choice B rationale
Recording blood pressure in the upper extremities alone is not sufficient. Coarctation of the aorta often presents with a discrepancy between upper and lower extremity blood pressures.
Choice C rationale
Assessing for the presence of femoral pulses is crucial. In coarctation of the aorta, there is decreased blood flow to the lower extremities, leading to weak or absent femoral pulses.
Choice D rationale
Observing for excessive crying is non-specific and can be associated with many conditions, not just coarctation of the aorta.