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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. A residual of 65 mL may indicate delayed gastric emptying, but it alone does not directly correlate with an increased risk of aspiration unless it leads to significant overdistension or the client is unable to tolerate further feedings.
B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.
C. Correct. his factor increases the risk for aspiration. Clients with gastroesophageal reflux disease (GERD) are more prone to refluxing contents from the stomach into the esophagus, which can lead to aspiration, especially during or after feedings.
D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.
Correct Answer is D
Explanation
Choice A rationale:
An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.
Choice B rationale:
An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.
Choice C rationale:
Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.
Choice D rationale:
A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.
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