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 A
Explanation
Choice A rationale
The inability to stand upright without support at 15 months is a developmental delay that should be reported to the provider. By this age, most toddlers can stand and walk independently. Delays in motor skills can indicate underlying neurological or musculoskeletal issues.
Choice B rationale
Building a tower of six to seven cubes is a skill typically developed by 24 months. At 15 months, a toddler may only be able to stack two to three cubes.
Choice C rationale
Jumping with both feet is a skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to be able to jump with both feet.
Choice D rationale
Turning a doorknob is a fine motor skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to have this skill.
Correct Answer is C
Explanation
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.