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 C
Explanation
Choice A rationale
Offering clear liquids for the first 24 hours is not necessary after a cardiac catheterization. The child can resume a normal diet as tolerated unless otherwise instructed by the healthcare provider. Clear liquids are typically recommended after procedures involving the gastrointestinal tract to prevent nausea and vomiting, but this is not the case here.
Choice B rationale
Keeping the child home for a week is not required. The child can usually return to normal activities within a day or two, depending on the healthcare provider’s instructions. Prolonged rest is not necessary unless there are complications or specific instructions from the healthcare provider.
Choice C rationale
Acetaminophen is recommended for discomfort because it is effective in managing mild to moderate pain and has a low risk of side effects. It is important to avoid medications that can increase bleeding risk, such as aspirin or ibuprofen, especially after a procedure like cardiac catheterization.
Choice D rationale
Assisting the child to take a tub bath for the first 3 days is not recommended. It is generally advised to avoid submerging the catheter insertion site in water to prevent infection. Sponge baths are usually recommended until the site has healed.
Correct Answer is A
Explanation
Choice A rationale
Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.
Choice B rationale
Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.
Choice C rationale
Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.
Choice D rationale
Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.