A nurse is assessing an infant with suspected gastroenteritis. Which assessment finding should be reported immediately?
Dry lips and sunken fontanelle
Slightly decreased urine output
Mild irritability during feedings
Occasional vomiting after feeds
The Correct Answer is A
A) Correct. Dry lips and a sunken fontanelle are signs of severe dehydration in an infant and require immediate attention.
B) Incorrect. While decreased urine output is a concern, it may not necessitate immediate reporting if it is only slightly decreased.
C) Incorrect. Mild irritability during feedings is a symptom of discomfort but may not necessitate immediate reporting.
D) Incorrect. Occasional vomiting after feeds is a common symptom of gastroenteritis and may not necessitate immediate reporting.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While gastroenteritis can lead to complications, permanent damage to the liver and kidneys is not a typical long-term effect.
B) Correct. One possible long-term effect of gastroenteritis is the development of irritable bowel syndrome (IBS), which can lead to chronic gastrointestinal symptoms.
C) Incorrect. Chronic fatigue may occur during the acute phase of gastroenteritis, but it is not a typical long-term effect.
D) Incorrect. While long-term effects are not extremely common, they can occur, especially in cases of severe or prolonged gastroenteritis.
Correct Answer is C
Explanation
A) Incorrect. Mild abdominal cramping and bloating are common symptoms of gastroenteritis and may not require immediate intervention.
B) Incorrect. While absence of bowel movements for 24 hours is concerning, it may not be an immediate emergency compared to other options.
C) Correct. The presence of blood in stool or dark, tarry stools indicates potential gastrointestinal bleeding, which requires immediate attention.
D) Incorrect. Nausea and occasional vomiting are common symptoms of gastroenteritis and may not be an immediate concern.
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