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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Related Questions
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.
Correct Answer is A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
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