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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Placing the client in seclusion is not an appropriate intervention for managing mania.
B. Incorrect. Encouraging the client to spend time in the dayroom may exacerbate symptoms of mania by providing more stimulation.
C. Correct. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.
D. Incorrect. Withdrawing privileges are not directly related to managing manic symptoms and may not be therapeutic.
Correct Answer is A
Explanation
A. Correct. At 12 weeks of gestation, the nurse should position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
B. Fundal height measurement is used to assess uterine growth and is not applicable for assessing fetal heart rate.
C. Placing the client in a side-lying position is not necessary for assessing fetal heart rate at 12 weeks of gestation.
D. Leopold maneuvers are used to determine fetal position and lie and are not directly related to auscultating the fetal heart rate.
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