A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.
The child weighs 33 lb.
Which of the following actions should the nurse take?
Notify the provider.
Continue to monitor the client.
Perform a bladder scan at the bedside.
Provide oral rehydration fluids.
The Correct Answer is B
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Contact the provider to clarify the dosage and frequency of medication administration.
The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
Correct Answer is C
Explanation
Neural tube defects are birth defects of the brain, spine, or spinal cord that happen in the first month of pregnancy.
Spina bifida is a neural tube defect that affects the spine.
Choice A, Hydrocephalus, is not a neural tube defect but rather a condition where there is an accumulation of cerebrospinal fluid within the brain.
Choice B, Cerebral palsy, is not a neural tube defect but rather a group of disorders that affect movement and muscle tone or posture.
Choice D, Muscular dystrophy, is not a neural tube defect but rather a group of genetic diseases that cause progressive weakness and loss of muscle mass.
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