A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Pale and a 24-hr fluid deficit of 30 mL
Decreased appetite and irritability
Temperature 38° C (100.4° F) and pulse rate 124/min
Sunken fontanels and dry mucous membranes
The Correct Answer is D
A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The test is not repeated at 2 months unless results are inconclusive.
B. Blood for the test is collected from the newborn’s heel, not the inner elbow.
C. Newborn genetic screening should be performed after 24 hours of age, once the baby has had adequate feedings, which ensures accurate metabolic screening.
D. The baby does not need to drink water before the test.
Correct Answer is C
Explanation
A. Sitting on the bed may invade the client’s personal space.
B. Standing while talking to the client may create a power imbalance and discomfort.
C. Sitting in a chair next to the bed places the nurse at eye level with the client, fostering comfort and effective communication.
D. Standing while talking to the client may create a power imbalance and discomfort.
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