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
A diastolic murmur is not a typical finding in coarctation of the aorta. This condition is more commonly associated with systolic murmurs.
Choice B rationale
Hypotension is not a common finding in coarctation of the aorta. In fact, hypertension in the upper extremities is more typical due to the narrowing of the aorta.
Choice C rationale
Excessive crying is not a specific indicator of coarctation of the aorta. It can be a symptom of many different conditions and is not diagnostic.
Choice D rationale
Unequal upper and lower extremity pulses are a key finding in coarctation of the aorta. The narrowing of the aorta causes reduced blood flow to the lower extremities, resulting in weaker pulses compared to the upper extremities.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a hallmark symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, causing forceful expulsion of stomach contents. This symptom typically appears in infants between 3 to 6 weeks of age.
Choice B rationale
A rigid abdomen is not a typical symptom of pyloric stenosis. It may indicate other abdominal issues, such as peritonitis or bowel obstruction.
Choice C rationale
Red currant jelly stools are associated with intussusception, not pyloric stenosis. Intussusception involves the telescoping of one part of the intestine into another, leading to bowel obstruction and characteristic stool appearance.
Choice D rationale
Distended neck veins are not related to pyloric stenosis. This symptom is more commonly associated with cardiac conditions or severe respiratory distress.