A nurse is assessing a child who has rhabdomyosarcoma of the nasopharynx. What is an expected finding for this malignancy?

The correct answer is: B. I will add Polycose to each of my baby's bottles.

Choice A reason:

Allowing the baby to take as much time as needed to finish the bottle is not ideal for infants with heart failure. These infants often tire easily and may not consume enough calories if feeding sessions are prolonged. Shorter, more frequent feedings are generally recommended to ensure adequate intake without exhausting the infant.

Choice B reason:

Adding Polycose to each bottle is an effective way to increase the caloric density of the infant's feedings. Infants with heart failure have higher caloric needs due to their increased metabolic demands and may struggle to consume enough calories through regular formula or breast milk alone. Polycose, a carbohydrate supplement, helps meet these increased nutritional needs.

Choice C reason:

Feeding the baby on a schedule every 4 hours may not be sufficient for an infant with heart failure. These infants often require more frequent feedings to meet their caloric needs and to prevent fatigue during feeding. Feeding every 1-3 hours is typically recommended to ensure they receive adequate nutrition.

Choice D reason:

Limiting the baby's crying to 15 minutes prior to each feeding does not directly address the nutritional needs of an infant with heart failure. While managing crying is important to reduce energy expenditure, the focus should be on providing adequate nutrition through frequent, high-calorie feedings.

The correct answer is: d. Capillary refill less than 3 seconds

Choice A: Heart rate 130/min

A heart rate of 130 beats per minute (bpm) is considered high for a 3-year-old child. Normal heart rates for children aged 1-3 years typically range from 80 to 120 bpm. While dehydration can cause tachycardia (increased heart rate), a heart rate of 130 bpm does not necessarily indicate effective rehydration.

Choice B: Urine specific gravity 1.015

Urine specific gravity measures the concentration of solutes in the urine. Normal ranges for urine specific gravity in children are typically between 1.005 and 1.030. A value of 1.015 falls within the normal range, suggesting adequate hydration. However, it is not the most direct indicator of effective rehydration therapy.

Choice C: Respiratory rate 24/min

The normal respiratory rate for a 3-year-old child is between 20 and 30 breaths per minute. A respiratory rate of 24 breaths per minute is within this normal range. While a normal respiratory rate can indicate improved hydration status, it is not the most specific indicator of effective rehydration therapy.

Choice D: Capillary refill less than 3 seconds

Capillary refill time is a reliable indicator of effective rehydration. Normal capillary refill time is less than 2 seconds. A capillary refill time of less than 3 seconds suggests that the child’s circulatory status has improved, indicating effective rehydration therapy. This is a direct and observable sign that the child’s perfusion and hydration status have normalized.