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 D
Explanation
Choice A rationale
Sitting on a nurse’s lap leaning forward is a position that can be used for postural drainage in infants with cystic fibrosis. This position helps drain secretions from the upper lobes of the lungs.
Choice B rationale
The supine position (lying on the back) is also used for postural drainage to target different areas of the lungs. It is not contraindicated for infants with cystic fibrosis.
Choice C rationale
Sitting on a nurse’s lap leaning backward is another position that can be used for postural drainage. This position helps drain secretions from the lower lobes of the lungs.
Choice D rationale
The Trendelenburg position (lying flat on the back with the feet elevated higher than the head) is contraindicated for infants with cystic fibrosis. This position can increase the risk of gastroesophageal reflux and aspiration, which can worsen respiratory symptoms.