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
ChoiceA rationale
Theapexoftheheart(apicalpulse)isthepreferredsiteforassessingtheheartrateininfants.It is located at the point of maximal impulse (PMI) and provides the most accuratemeasurementof theheartrateinthisagegroup.
ChoiceB rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it canbeused forbloodpressuremeasurement,itisnotasaccurateastheapicalpulseforheartrateassessment.
ChoiceCrationale
Theradialarteryisnottypicallyusedforassessingthe heartrateininfants.Itismorecommonlyusedinolderchildren andadults.
ChoiceD rationale
Thecarotidarteryisnotrecommendedforassessingtheheartrateininfantsduetotheriskofcompressingtheairwayandcausingdiscomfort.
Correct Answer is A
Explanation
Choice A rationale
Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.
Choice B rationale
Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Choice C rationale
Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.
Choice D rationale
Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.