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
At 10 months, infants are typically able to imitate simple sounds, including animal sounds. This is a normal developmental milestone.
Choice B rationale
Turning pages in a book is a fine motor skill that develops later, around 12 months of age.
Choice C rationale
Building a tower of three or four cubes is a skill that typically develops around 15-18 months of age.
Choice D rationale
By 10 months, infants should be able to sit steadily without support. Inability to do so may indicate a developmental delay.
Correct Answer is D
Explanation
Choice A rationale
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.