A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

13% weight loss.

Bulging anterior fontanel.

Bradypnea.

Capillary refill 3 seconds.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale

A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.

Choice B rationale

A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.

Choice C rationale

Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.

Choice D rationale

A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale

At 10 months, infants are typically able to imitate simple sounds, including animal sounds. This is a normal developmental milestone.

Choice B rationale

Turning pages in a book is a fine motor skill that develops later, around 12 months of age.

Choice C rationale

Building a tower of three or four cubes is a skill that typically develops around 15-18 months of age.

Choice D rationale

By 10 months, infants should be able to sit steadily without support. Inability to do so may indicate a developmental delay.

A. Projectile vomiting. B. Rigid abdomen. C. Red currant jelly stools. D. Distended neck veins.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Projectile vomiting is a hallmark symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, causing forceful expulsion of stomach contents. This symptom typically appears in infants between 3 to 6 weeks of age.

Choice B rationale

A rigid abdomen is not a typical symptom of pyloric stenosis. It may indicate other abdominal issues, such as peritonitis or bowel obstruction.

Choice C rationale

Red currant jelly stools are associated with intussusception, not pyloric stenosis. Intussusception involves the telescoping of one part of the intestine into another, leading to bowel obstruction and characteristic stool appearance.

Choice D rationale

Distended neck veins are not related to pyloric stenosis. This symptom is more commonly associated with cardiac conditions or severe respiratory distress.

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A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

Explanation

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