A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?
Flat anterior fontanel
Oliguria
Oral intake of 4 oz every 3 hr
Capillary refill 4 seconds
The Correct Answer is C
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Brainstorming sessions with nurses can generate new ideas and perspectives to address public health concerns such as rising rates of sexually transmitted infections. It allows for creative
thinking and collaboration among team members.
B. While a community-wide program may be part of the solution, it may not directly involve generating new ideas within the healthcare team.
C. Role-playing with nurses may be beneficial for training and education purposes but may not specifically focus on generating new ideas to address the public health concern.
D. Personal discussions with clients may provide valuable insights into individual experiences and needs but may not be the most effective method for generating new ideas on a broader scale to address community-wide concerns.
Correct Answer is B
Explanation
A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.
B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.
C. Not having a bowel movement since prior to admission is not an urgent concern in the
immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.
D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.
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