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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.

B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.

C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.

D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.

A. "The nurse will initiate acupuncture when I arrive at the unit." B. "I can use my ultrasound picture as a focal point during contractions." C. "A transcutaneous electrical nerve stimulator will help with pelvic pressure." D. "My nurse can teach me biofeedback at the beginning of labor."

Correct Answer is B

Explanation

A. "The nurse will initiate acupuncture when I arrive at the unit.": Acupuncture must be performed by a trained and licensed practitioner, not a bedside nurse. While it can be used for labor pain, it is not typically initiated by nursing staff upon admission.

B. "I can use my ultrasound picture as a focal point during contractions.": Focal point techniques, such as concentrating on a meaningful object like an ultrasound picture, help distract from pain and promote relaxation.

C. "A transcutaneous electrical nerve stimulator will help with pelvic pressure.": TENS units are primarily effective for back pain in early labor rather than pelvic pressure. They work by stimulating sensory nerves to reduce pain perception but are less effective for deep pelvic discomfort.

D. "My nurse can teach me biofeedback at the beginning of labor.": Biofeedback requires prior training and practice before labor begins to be effective. Learning it for the first time during active labor is impractical and unlikely to yield good results.

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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?

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