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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A soft diet is appropriate for a toddler who has a cleft palate repair, as it prevents trauma to the surgical site and promotes healing. The nurse should avoid foods that are hard, sticky, or spicy.
Choice B reason: Offering fluids through a straw is not an appropriate action, as it can create negative pressure in the mouth and disrupt the suture line. The nurse should offer fluids with a cup or a spoon.
Choice C reason: Administering opioids for pain is not an appropriate action, as opioids can cause respiratory depression and sedation in toddlers. The nurse should use non-opioid analgesics such as acetaminophen or ibuprofen, unless otherwise prescribed.
Choice D reason: Applying bilateral wrist restraints is not an appropriate action, as it can cause injury and distress to the toddler. The nurse should use other methods to prevent the toddler from touching the surgical site, such as distraction, toys, or mittens.
Correct Answer is B
Explanation
The correct answer is b. 2 mL/kg/hr. This is within the normal range for infants, indicating adequate hydration.
Choice A reason:
0.5 mL/kg/hr: This is below the normal range for infants, indicating possible dehydration3. Normal urinary output for infants is typically 1-2 mL/kg/hr.
Choice B reason:
2 mL/kg/hr: This is within the normal range for infants, indicating that the fluid imbalance has been corrected.
Choice C reason:
15 mL/kg/hr: This is excessively high and could indicate overhydration or other issues1. Such high output is not typical for infants.
Choice D reason:
75 mL/kg/hr: This is extremely high and unrealistic for normal urinary output1. It suggests a measurement error or a severe medical condition.
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