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
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended method for managing nosebleeds. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice B rationale
Sitting the child upright and leaning slightly forward while applying pressure to the sides of the nose is the correct method. This position helps prevent blood from flowing into the throat and allows it to clot more effectively.
Choice C rationale
Having the child lie flat and apply pressure to the cheeks is not effective for stopping a nosebleed. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice D rationale
Putting the child in bed, elevating the head slightly, and pressing on the forehead is not effective for stopping a nosebleed. The pressure needs to be applied directly to the soft part of the nose to control the bleeding.
Correct Answer is C
Explanation
Choice A rationale
The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.
Choice B rationale
The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.
Choice C rationale
The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.
Choice D rationale
The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.