A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?
"Your baby needs an IV because she is breathing slower than normal."
"Your baby needs an IV because her heart rate is decreased."
"Your baby needs an IV because her fontanels are bulging."
"Your baby needs an IV because she is not producing tears."
The Correct Answer is D
Rationale:
A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.
B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.
C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.
D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.
B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.
C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.
D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.
Correct Answer is C
Explanation
A. "Wear a pair of disposable briefs at bedtime.": Using briefs may provide protection against leakage but does not address the underlying bladder control issue. Bladder retraining focuses on strengthening muscles and establishing voiding schedules.
B. "Limit oral fluid intake to 1,000 milliliters per day.": Restricting fluids can lead to dehydration and urinary tract infections. Adequate hydration is important for bladder health, and fluid restriction is not a recommended strategy for retraining.
C. "Practice pelvic-floor exercises regularly.": Pelvic-floor (Kegel) exercises strengthen the muscles that support bladder control, improve continence, and are a key component of bladder retraining programs. Consistent practice enhances effectiveness over time.
D. "Drink 8 ounces of citrus juice per day.": Citrus juice is not necessary for bladder retraining and may irritate the bladder in some individuals. Dietary recommendations should focus on overall hydration and bladder-friendly fluids rather than specific juices.
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