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?
Skin integrity
Respiratory rate
Body weight
Blood pressure
The Correct Answer is C
In an infant with a history of vomiting and fever, body weight is the most reliable indicator of fluid loss. Monitoring the infant's weight over time can help assess the degree of dehydration and guide the appropriate fluid replacement therapy. A significant decrease in body weight suggests significant fluid loss.
Option A: Skin integrity is important to assess for signs of dehydration, but it is not as reliable as body weight in determining the extent of fluid loss.
Option B: Respiratory rate can be affected by various factors and is not a direct indicator of fluid loss.
Option D: Blood pressure is not the most reliable indicator of fluid loss in an infant with dehydration. In severe cases of dehydration, blood pressure can drop, but it is not as sensitive as body weight in assessing the extent of fluid loss.
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Correct Answer is C
Explanation
Rheumatic fever (RF) is a complication that can occur after an untreated or inadequately treated streptococcal throat infection (strep throat). It can affect the heart, joints, skin, and brain. One important aspect of managing RF is to prevent further episodes of strep throat, as it can trigger recurrent RF. Therefore, the child with a history of RF will require prophylactic antibiotics (usually penicillin or a related antibiotic) before certain invasive procedures, dental work, or surgeries to prevent strep throat and subsequent recurrence of RF.
Option A is not specific to rheumatic fever, and while electrolyte imbalances may be monitored and managed in certain cases of severe illness, it is not a core aspect of managing RF.
Option B is not accurate. While many children with RF do recover fully with appropriate treatment, they may be at risk of developing rheumatic heart disease, which can lead to long-term complications if not managed properly.
Option D is not a direct implication of RF. Rheumatic fever is not a genetically inherited condition, but a complication of strep throat caused by a bacterial infection. There is no evidence to suggest that having RF would directly affect the genetic implications for future offspring.
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.
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