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

Answer and Explanation

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 A

Explanation

A. "I will keep my baby in an upright position after feedings."
Gastroesophageal reflux (GER) is a condition where the stomach contents flow back into the esophagus, which can cause spitting up or regurgitation in infants. Keeping the baby in an upright position after feedings can help reduce the likelihood of reflux episodes. By holding the baby in an upright position for about 30 minutes after feeding, gravity can aid in keeping the stomach contents from flowing back into the esophagus.
The other statements are incorrect or do not address the management of gastroesophageal reflux:
B. "My baby's formula can be thickened with oatmeal." - Thickening formula with oatmeal is not a standard recommendation for managing GER in infants. In some cases, thickening formulas may be recommended, but it should be done under the guidance of a healthcare provider.
C. "I should position my baby side-lying during sleep." A side-lying position is not recommended for sleep in infants, as it increases the risk of sudden infant death syndrome (SIDS). The safe sleep position for infants is on their back.
D. "I will have to feed my baby formula rather than breast milk." - The type of feeding (formula or breast milk) does not directly impact the occurrence of gastroesophageal reflux. Both breast milk and formula can cause reflux in some infants. It is essential to discuss feeding options with a healthcare provider to determine the best approach for the individual infant's needs.

A. Encourage the parents to rock the infant. B. Administer ibuprofen as needed for pain. C. Position the infant on her abdomen. D. Offer the infant a pacifier

Correct Answer is A

Explanation

Correct answer: A
A. Encourage the parents to rock the infant:Rocking provides comfort and soothing for the infant. It helps reduce anxiety and promotes relaxation during the immediate postoperative period

B. Administer ibuprofen as needed for pain:Administering ibuprofen as needed for pain is not typically recommended for infants under 6 months of age without specific instructions from the healthcare provider. Ibuprofen is generally avoided in young infants due to potential risks of adverse effects, especially in the immediate postoperative period
C. Position the infant on her abdomen: After cleft lip repair surgery, it is generally recommended to position the infant on her back to prevent any pressure on the surgical site and to minimize the risk of infection. Placing the infant on her abdomen may interfere with the healing process and increase the risk of complications.

D. Offer the infant a pacifier.
Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.

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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?

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