A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor?
Bulging fontanel
Weight loss
Distended jugular vein
Bradycardia
The Correct Answer is B
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply a cool cloth to the infant's heel 5 min prior to the procedure: Cooling the skin can cause vasoconstriction, making the heel stick more difficult and potentially increasing discomfort. This intervention does not support pain reduction and may prolong the procedure, which can further distress the infant.
B. Promote skin-to-skin contact with the infant's guardian during the procedure: Skin-to-skin contact is an evidence-based method that reduces procedural pain in infants by stabilizing heart rate, enhancing comfort, and lowering stress responses. It offers both analgesic and calming effects, making it an effective strategy during heel sticks.
C. Provide the infant with a bottle of water during the procedure: Water does not provide analgesic benefit to infants and does not activate soothing mechanisms such as the sucrose-induced endorphin release used for pain relief. Offering plain water may also be inappropriate for young infants due to risk of water intoxication.
D. Apply lidocaine/prilocaine cream 15 min prior to the procedure: This topical anesthetic requires significantly longer, typically 30 to 60 minutes, to achieve adequate analgesic effect. Applying it only 15 minutes before the heel stick would not provide sufficient pain control, limiting its effectiveness.
Correct Answer is D
Explanation
A. "The item serving size is consistent from one manufacturer to the next.": Serving sizes can vary between different manufacturers and products. Clients should read the label carefully for the specific serving size of each item, as it is not standardized across brands.
B. “The daily values relate to a 1,500-calorie diet.": Daily values on nutrition labels are based on a 2,000-calorie diet, not 1,500 calories. Understanding this helps clients interpret percentages correctly in the context of their individual dietary needs.
C. "Food manufacturers provide nutrition information voluntarily.": Nutrition labeling is required by law for most packaged foods. It is not voluntary, and clients should understand that these labels are standardized and regulated.
D. "The ingredient with the greatest weight appears first.": Ingredients on nutrition labels are listed in descending order by weight. The first ingredient is present in the largest amount, which helps clients make informed choices about food composition.
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