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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Related Questions
Correct Answer is C
Explanation
A. Incorrect. It's important to alternate breasts during feedings to ensure both breasts are stimulated and milk supply is well-maintained.
B. Incorrect. Manually expressing milk can help stimulate milk production and maintain milk supply; it typically does not decrease milk supply.
C. Correct. Frequent and effective breastfeeding, along with proper latching and milk removal, stimulates the production of more milk.
D. Incorrect. Breastfeeding should continue for as long as the baby is actively sucking and swallowing. Babies vary in their feeding patterns, and the length of time at each breast can differ. It's essential to ensure the baby is adequately fed and empties the breast to stimulate milk supply.
Correct Answer is B
Explanation
A. Incorrect. A client receiving heparin for deep-vein thrombosis should not be discharged early.
B. Correct. This client is the most appropriate candidate for early discharge in anticipation of multiple client admissions. Vertebroplasty is a minimally invasive procedure that typically requires only a short hospital stay. The client is likely stable at 1 day post-procedure and can be discharged with appropriate follow-up care.
C. Incorrect. A client with COPD and a respiratory rate of 44/min needs immediate attention, not early discharge.
D. Incorrect. This client is stable for discharge, as sealed radiation implants typically do not require hospitalization after a certain point, assuming they are stable and able to manage their care at home. Discharging this client can help free up resources for incoming patients, provided they have appropriate support at home.
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