A clinic nurse is caring for a 4-year-old client with acute diarrhea and mild dehydration who is afebrile, active, and alert. The nurse is providing instructions to the parent. Which statement by the parent indicates understanding?
"We can anticipate needing intravenous fluids to correct the dehydration."
"I will continue to give oral rehydration in small amounts."
"Chicken broth will replace the needed electrolytes lost."
"If my child's soft spot becomes depressed, I will notify the healthcare provider immediately."
The Correct Answer is B
Rationale:
A. Intravenous fluids are generally not required if the child is alert and active with mild dehydration; oral rehydration is usually sufficient.
B. Oral rehydration solutions are appropriate for treating mild dehydration and should be given in small amounts frequently.
C. Chicken broth is not ideal for replacing electrolytes because it is low in electrolytes and high in sodium. Oral rehydration solutions are preferred.
D. A depressed soft spot (fontanel) is a sign of severe dehydration in infants. For a 4-year-old, signs of dehydration would include changes in urine output, thirst, or dry mucous membranes rather than a depressed fontanel.
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Correct Answer is A
Explanation
Rationale:
A. Myelomeningocele is a type of spina bifida where there is a protrusion of the meninges and spinal cord through a defect in the vertebrae. This condition can result in partial to complete paralysis in the lower extremities due to the involvement of the spinal cord.
B. A unilateral port-wine birthmark is typically associated with conditions like Sturge-Weber syndrome, not myelomeningocele.
C. A protruding sac containing abdominal contents is characteristic of omphalocele, not myelomeningocele.
D. Fusion of cranial suture lines is not associated with myelomeningocele but rather with craniosynostosis.
Correct Answer is C
Explanation
Rationale:
A. A capillary refill greater than 3 seconds suggests ongoing dehydration and poor perfusion, indicating that oral rehydration has not been fully effective.
B. A respiratory rate of 24/min is within normal limits for a 4-year-old but is not a direct indicator of hydration status.
C. A urine specific gravity of 1.015 is within the normal range, indicating adequate hydration and that oral rehydration therapy has been effective.
D. A heart rate of 130 bpm, while potentially normal for a 4-year-old, does not specifically indicate the effectiveness of rehydration therapy.