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
The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants. It is located at the point of maximal impulse (PMI) and provides the most accurate measurement of the heart rate in this age group.
Choice B rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it can be used for blood pressure measurement, it is not as accurate as the apical pulse for heart rate assessment.
Choice C rationale
The radial artery is not typically used for assessing the heart rate in infants. It is more commonly used in older children and adults.
Choice D rationale
The carotid artery is not recommended for assessing the heart rate in infants due to the risk of compressing the airway and causing discomfort.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Rheumatic fever is often preceded by a streptococcal infection, such as strep throat. A sibling with a sore throat 3 weeks ago could have had a strep infection, which is a significant risk factor for developing rheumatic fever.
Choice B rationale
Chickenpox is caused by the varicella-zoster virus and is not related to rheumatic fever, which is a complication of streptococcal infections.
Choice C rationale
Gastritis is an inflammation of the stomach lining and is not associated with rheumatic fever.
Choice D rationale
Fifth disease is caused by parvovirus B19 and is not related to rheumatic fever.
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