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 {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
A. Hypoglycemia might be a concern if the baby had risk factors like maternal diabetes, but this information is not provided.
B. Tachycardia is not mentioned as a concern in the scenario, and the heart rate is within normal limits for a newborn
C. Bronchopulmonary Dysplasia (BPD): The newborn's respiratory rate is increasing over time, along with the presence of grunting and retractions. These are signs of respiratory distress. Bronchopulmonary dysplasia (BPD) is a chronic lung disease that primarily affects premature infants who require mechanical ventilation and oxygen therapy for an extended period. The symptoms align with the respiratory distress and could suggest a risk for BPD.
D. Transient Tachypnea of the Newborn (TTN): The newborn's respiratory rate is increasing over time, along with grunting and retractions. These signs are consistent with transient tachypnea of the newborn, which is a self-limiting condition characterized by rapid breathing shortly after birth. It is more common in infants born via cesarean delivery and may result from delayed clearance of lung fluid.
Correct Answer is D
Explanation
A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.
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