A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Bulging anterior fontanel
Decreased temperature
Hypertension
Oliguria
The Correct Answer is D
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
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Related Questions
Correct Answer is C
Explanation
A. "Take your temperature every night before going to bed." Basal body temperature (BBT) must be measured after a full night’s sleep, not at bedtime, to accurately detect ovulatory shifts in temperature.
B. "Take your temperature 1 hour after getting out of bed." Delaying the measurement even by an hour can alter the results, as physical activity and environmental exposure can cause inaccurate readings.
C. "Take your temperature immediately after waking and before getting out of bed." This is the correct instruction. BBT should be taken at the same time each morning, right after waking, before any activity, to detect the slight rise in temperature (0.3–0.6°C or 0.5–1.0°F) that typically follows ovulation.
D. "Take your temperature within 30 minutes after your first morning void." Waiting until after voiding can also affect the reading. The temperature should be taken prior to any physical movement, including going to the bathroom, for best accuracy.
Correct Answer is B
Explanation
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
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