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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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 A
Explanation
Choice A rationale
A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.
Choice B rationale
A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.
Choice C rationale
Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.
Choice D rationale
A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.