A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information the nurse documents that the infant has:
Severe dehydration.
Risk for fluid volume deficit.
Failure to thrive.
Malabsorption syndrome
The Correct Answer is A
A. A weight loss of 10% or more in infants within a short period is indicative of severe dehydration. The significant weight loss from 5 kg to 4.3 kg confirms this diagnosis.
B. The risk for fluid volume deficit would be noted if there were signs of potential dehydration, but in this case, the infant has already lost a significant amount of weight, confirming severe dehydration.
C. Failure to thrive is a diagnosis related to insufficient weight gain over time, rather than acute weight loss due to dehydration.
D. Malabsorption syndrome could contribute to chronic weight loss, but the acute loss in this case is more likely due to dehydration from diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Doll's eye reflex is expected to be negative in older infants. It is present in newborns but should be absent by 2 months of age.
B. The Crawl reflex, which involves the infant moving forward when placed on their stomach, should disappear by 6-8 months. A negative reflex at 9 months is expected.
C. The Babinski reflex, where the toes fan out when the sole of the foot is stroked, is normal in infants up to 12-18 months.
D. The Moro reflex, or startle reflex, should disappear by 4-6 months of age. A positive Moro reflex at 9 months indicates a delay in neurological development and requires further evaluation.
Correct Answer is B
Explanation
Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.
B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.
C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.
D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.
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