A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect?
Irritability
Tetany
slow, bounding pulse
Decreased temperature
The Correct Answer is A
The nurse should expect to find irritability in an infant who is dehydrated. Dehydration in infants can lead to changes in behavior and irritability due to the imbalance in fluid and electrolytes. Other common signs of dehydration in infants may include:
Poor skin turgor (skin tenting)
Sunken fontanelles (soft spots on the baby's head)
Dry mucous membranes (dry mouth and tongue)
Decreased urine output or concentrated urine
Rapid heart rate (tachycardia)
Increased respiratory rate
Sunken eyes
Decreased tears when crying
B. Tetany is a condition characterized by involuntary muscle contractions and is more commonly associated with hypocalcemia (low calcium levels) rather than dehydration.
C. A slow, bounding pulse is not typically associated with dehydration. Dehydration often leads to a rapid heart rate (tachycardia) as the body attempts to compensate for the loss of fluid.
D. Decreased temperature is not a typical finding in dehydration. Dehydration can lead to fever in some cases due to an underlying infection, but it does not cause a decrease in body temperature on its own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When assessing the heart rate in an infant, the nurse should use the brachial artery. The brachial artery is located in the upper arm, and it is easily accessible in infants for measuring the heart rate by palpation. The other sites mentioned are not typically used for heart rate assessment in infants.
Option A (Apex of the heart) is not a site for directly measuring the heart rate; it is a location on the chest where the heartbeat can be heard most clearly with a stethoscope.
Option B (Carotid artery) is a site commonly used to assess the pulse in older children and adults but is generally not used for infants due to its location and risk of injury.
Option D (Radial artery) is a site commonly used to assess the pulse in older children and adults, but it can be challenging to locate and accurately measure in infants, especially during emergency situations. The brachial artery is the preferred site for infants.
Correct Answer is C
Explanation
Infants with gastroesophageal reflux should be placed in an infant seat or an upright position after feedings to help prevent regurgitation and aspiration of stomach contents into the airway. Placing the infant in an upright position facilitates gravity-assisted movement of stomach contents down and away from the esophagus, reducing the likelihood of reflux. It is essential to ensure that the infant seat is appropriate for the child's age and size and that the infant is safely secured within it.
The other options are not recommended for infants with gastroesophageal reflux:
When caring for an infant with gastroesophageal reflux (GER), the nurse should place the infant in an infant seat or an upright position following feedings. Placing the infant in an upright position helps to reduce the risk of reflux and regurgitation. Gravity can assist in keeping the stomach contents from flowing back into the esophagus, reducing the potential for discomfort and reflux symptoms.
The other options are not recommended for an infant with GER:
A. Placing the infant in a prone position (lying on the stomach) after feedings can increase the risk of choking and aspiration. It is essential to avoid this position, especially after feeding, to reduce the risk of reflux and its complications.
B. Placing the infant on his left side is not the preferred position for GER management. While the left side is often recommended for sleeping to reduce the risk of sudden infant death syndrome (SIDS), it is not specifically indicated for GER management after feedings.
D. Placing the infant on his right side is also not the preferred position for GER management after feedings. The right side does not provide the benefits of an upright position in reducing the risk of reflux and regurgitation.
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