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

Sunken fontanels and dry mucous membranes

Temperature 38°C (100.4°F) and pulse rate 124/min

Decreased appetite and irritability

Answer and Explanation

The Correct Answer is B

A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.

B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.

C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.

D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.

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Correct Answer is C

Explanation

A. Incorrect. Family history of malignant hypertension is not a contraindication for alteplase.

B. Incorrect. COPD itself is not a contraindication for alteplase. While it can complicate overall management, it does not increase the immediate risk of bleeding associated with thrombolytics.

C. Correct. Recent surgery, especially orthopedic surgery like hip arthroplasty, is a contraindication for thrombolytic therapy due to the increased risk of bleeding and hematoma formation at the surgical site.

D. Incorrect. Acute renal failure from six months ago is not a contraindication for alteplase.

A. "You can receive the immunization for influenza at any time during your pregnancy." B. "The hepatitis B immunization should not be obtained until after you finish breastfeeding." C. "You can receive the rubella immunization during the third trimester of pregnancy." D. "The immunization for varicella should be given at least 1 month prior to delivery."

Correct Answer is A

Explanation

A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.

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A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

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