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 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.
Correct Answer is B
Explanation
Choice A rationale
Restraining the child’s arms during a seizure is not recommended. Restraint can cause injury to the child and does not prevent the seizure from occurring. Instead, the focus should be on ensuring the child’s safety by removing any nearby objects that could cause harm.
Choice B rationale
Positioning the child laterally (on their side) is the correct action. This position helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration. It also facilitates better breathing and prevents the tongue from obstructing the airway.
Choice C rationale
Attempting to stop the seizure is not advisable. Seizures typically run their course and attempting to stop them can cause more harm than good. The nurse should focus on ensuring the child’s safety and monitoring the seizure’s duration and characteristics.
Choice D rationale
Using a padded tongue blade is outdated and not recommended. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or airway. It is better to ensure the child’s safety by positioning them laterally and monitoring their airway.