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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The nurse should first assess the client’s knowledge to determine her level of understanding before providing teaching or demonstration.
B. Supervising a return demonstration comes later after initial education.
C. Teaching the client how to insert the diaphragm is important, but assessment must be done first.
D. Documenting understanding is essential, but it is not the first step in client education.

A. Maintain eye contact with the newborn during feedings. B. Administer naloxone to the newborn. C. Minimize noise in the newborn's environment. D. Swaddle the newborn with his legs extended.

Correct Answer is C

Explanation

A. Avoid direct eye contact, as it can be overstimulating.
B. Naloxone is contraindicated in opioid-exposed newborns because it can cause severe withdrawal symptoms.
C. Newborns with neonatal abstinence syndrome (NAS) are easily overstimulated, so a quiet, dimly lit environment helps reduce stress.
D. Swaddling is beneficial, but the legs should be flexed, not extended, to mimic a fetal position and promote comfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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