A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Heart rate 130/min
Urine specific gravity 1.015
Respiratory rate 24/min
Capillary refill less than 3 seconds
None
None
The Correct Answer is B
The correct answer is: b.
Choice A: Heart rate 130/min
A heart rate of 130 beats per minute (bpm) is considered high for a 3-year-old child. Normal heart rates for children aged 1-3 years typically range from 80 to 120 bpm. While dehydration can cause tachycardia (increased heart rate), a heart rate of 130 bpm does not necessarily indicate effective rehydration.
Choice B: Urine specific gravity 1.015
Urine specific gravity of 1.015 is within the normal range (1.005–1.030) for a hydrated child. Dehydration increases urine concentration (>1.020), but a normalized value like 1.015 shows that ORT has restored fluid balance. UpToDate and NIH studies (e.g., Binder et al., 2014) highlight urine specific gravity as a precise measure of hydration status, making it the strongest indicator of ORT effectiveness.
Choice C: Respiratory rate 24/min
The normal respiratory rate for a 3-year-old child is between 20 and 30 breaths per minute. A respiratory rate of 24 breaths per minute is within this normal range. While a normal respiratory rate can indicate improved hydration status, it is not the most specific indicator of effective rehydration therapy.
Choice D: Capillary refill less than 3 seconds
Capillary refill time of less than 3 seconds suggests adequate perfusion, as normal is under 2 seconds. Dehydration may prolong this time, but “less than 3 seconds” could include slightly delayed values (e.g., 2.5 seconds). UpToDate and NIH studies (e.g., Doan et al., 2010) note it as useful but less specific than urine specific gravity for confirming ORT effectiveness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Keeping the baby in an upright position after feedings is an effective strategy to prevent or reduce gastroesophageal reflux, as it allows gravity to help the stomach contents stay down. The parent should hold the baby upright for at least 20 to 30 minutes after each feeding, and avoid placing the baby in a car seat or swing, which can increase the abdominal pressure.
Choice B reason: Feeding the baby formula rather than breast milk is not necessary for gastroesophageal reflux, as breast milk is easier to digest and less likely to cause reflux than formula. The parent should continue to breastfeed the baby, unless there is a medical reason to switch to formula. The parent should also avoid overfeeding the baby, and burp the baby frequently during and after feedings.
Choice C reason: Positioning the baby lying on his stomach is not recommended for gastroesophageal reflux, as it can increase the risk of aspiration, suffocation, and sudden infant death syndrome (SIDS). The parent should place the baby on his back to sleep, and elevate the head of the crib or bassinet by 30 degrees to reduce the reflux.
Choice D reason: Thickening the baby's formula with honey is not advised for gastroesophageal reflux, as honey can cause botulism, a serious and potentially fatal illness, in infants under one year of age. The parent should not add any thickening agents to the formula, unless prescribed by the provider. Some studies suggest that thickening the formula with rice cereal may reduce the reflux, but the evidence is inconclusive and the practice may have adverse effects, such as increased caloric intake, constipation, or food allergies.
Correct Answer is C
Explanation
Choice A reason: Assessing the client's erythematous rash is an important action for the nurse to take, but it is not the priority. The rash is one of the minor criteria for diagnosing acute rheumatic fever, and it may not be present in all cases. The rash is usually non-pruritic and migratory, and it appears on the trunk and extremities.
Choice B reason: Identifying the degree of parental anxiety related to the diagnosis is an appropriate action for the nurse to take, but it is not the priority. The nurse should provide emotional support and education to the parents, and address their concerns and questions. However, this is not the most urgent action.
Choice C reason: Auscultating the rate and characteristics of the child's heart sounds is the priority action for the nurse to take, as it can detect the presence and severity of carditis, which is the most serious complication of acute rheumatic fever. Carditis is the inflammation of the heart muscle, valves, or pericardium, and it can cause murmurs, tachycardia, dysrhythmias, heart failure, or death.
Choice D reason: Using a pain-rating tool to determine the severity of the joint pain is an important action for the nurse to take, but it is not the priority. The joint pain is one of the major criteria for diagnosing acute rheumatic fever, and it is usually severe and migratory, affecting the large joints such as the knees, ankles, elbows, or wrists. The nurse should assess the pain level and provide analgesics and anti-inflammatory medications as prescribed.
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