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: Pain is an expected finding for a child who has appendicitis, as it is caused by the inflammation and infection of the appendix, which is a small pouch attached to the cecum. Pain usually begins around the umbilicus and then shifts to the right lower quadrant, and it may worsen with movement, coughing, or deep breathing.
Choice B reason: High fever is not an expected finding for a child who has appendicitis, as it indicates a severe infection or a perforation of the appendix, which can lead to peritonitis or sepsis. A mild fever may be present in some cases of appendicitis, but it is not a specific or reliable sign.
Choice C reason: Constipation is not an expected finding for a child who has appendicitis, as it is not related to the function or location of the appendix. Constipation may be caused by many other factors, such as dehydration, diet, medication, or bowel habits. Diarrhea may occur in some cases of appendicitis, but it is also not a specific or reliable sign.
Choice D reason: Bradycardia is not an expected finding for a child who has appendicitis, as it indicates a decreased heart rate, which can be a sign of shock, hypothermia, or cardiac problems. Bradycardia is defined as a heart rate below 60/min in children older than 1 year, or below 100/min in infants younger than 1 year. Tachycardia, or an increased heart rate, may occur in some cases of appendicitis, as a result of pain, fever, or dehydration.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because administering iron at bedtime can cause gastrointestinal upset and interfere with the child's sleep. Iron should be given between meals or one hour before meals for better absorption.
Choice B reason: This statement is correct because giving iron with orange juice or other foods rich in vitamin C can enhance iron absorption. Vitamin C helps convert iron into a form that is more easily absorbed by the body.
Choice C reason: This statement is incorrect because administering iron at mealtimes can reduce iron absorption. Iron can bind with certain substances in food, such as calcium, phytates, and tannins, and make it less available for the body.
Choice D reason: This statement is incorrect because giving iron with milk can decrease iron absorption. Milk contains calcium, which can interfere with iron absorption. Milk can also cause nausea and vomiting when taken with iron.
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