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:
Failure to thrive.
Malabsorption syndrome.
Severe dehydration.
Risk for fluid volume deficit.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.
Choice B rationale
A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.
Choice C rationale
Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.
Choice D rationale
A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.
Correct Answer is ["50"]
Explanation
Step 1 is: Calculate the total volume to be infused. 150 mL/hr × 12 hr = 1800 mL Step 2 is: Calculate the total drops per minute. (1800 mL ÷ 720 min) × 20 gtt/mL = 50 gtt/min
The final calculated answer is 50 gtt/min.
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