A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Blood pressure.
Respiratory rate.
Body weight.
Skin integrity.
The Correct Answer is C
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
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Correct Answer is B
Explanation
Choice A rationale
Isosorbide dinitrate is a nitrate used to treat angina and heart failure. It does not have contraindications for patients with asthma.
Choice B rationale
Carvedilol is a beta-blocker that can exacerbate asthma symptoms because it blocks beta-2 receptors in the lungs, leading to bronchoconstriction.
Choice C rationale
Captopril is an ACE inhibitor used to treat hypertension and heart failure. It does not have contraindications for patients with asthma.
Choice D rationale
Fluticasone is a corticosteroid used to manage asthma and does not have contraindications for patients with heart failure.
Correct Answer is B
Explanation
Choice A rationale
Giving an oral rehydration solution is not appropriate without first assessing the infant. Projectile vomiting in a 2-month-old could indicate a serious condition such as pyloric stenosis, which requires medical evaluation.
Choice B rationale
Bringing the baby to the clinic today is the appropriate response. Projectile vomiting in an infant can be a sign of a serious condition that requires prompt medical evaluation and treatment.
Choice C rationale
Switching to a different formula is not appropriate without first assessing the infant. Projectile vomiting could indicate a serious condition that needs to be evaluated by a healthcare provider.
Choice D rationale
Burping the baby more frequently during feedings may help with minor feeding issues, but it is not appropriate advice for projectile vomiting. The infant needs to be evaluated by a healthcare provider to determine the cause of the vomiting.