A nurse is caring for a toddler who has been vomiting for the past 8 hr. Which of the following findings indicates to the nurse that the child is dehydrated?
Increased blood pressure
Distended jugular veins
Flat anterior fontanel
Increased pulse
The Correct Answer is D
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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Related Questions
Correct Answer is D
Explanation
A. Haemophilus influenzae type b (Hib) vaccination is typically given to infants and toddlers, not to children who are 11 years old. The child would likely have already received this vaccine as part of their early childhood immunizations.
B. Hepatitis A vaccination is recommended for children, but it is typically given earlier in childhood (around 1 year of age), and would not be given at 11 years old unless it is part of a catch-up schedule.
C. Rotavirus vaccination is given to infants, and by the age of 11, the child should have completed the recommended series.
D. The Human papillomavirus (HPV) vaccine is recommended for children ages 11 to 12 years, making it appropriate for this child. The nurse should plan to administer the HPV vaccine as part of routine immunizations for this age group.
Correct Answer is C
Explanation
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
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