A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fruity breath odour: This is a sign of diabetic ketoacidosis (DKA), a condition associated with hyperglycemia, not hypoglycaemia.
B. Diaphoresis: Sweating is a common sign of hypoglycemia due to the body's release of adrenaline in response to low blood sugar levels.
C. Dry mucous membranes: This is typically associated with dehydration and hyperglycemia, not hypoglycaemia.
D. Polyuria: Frequent urination is a symptom of hyperglycemia, as the body tries to excrete excess glucose through the urine.
Correct Answer is A
Explanation
A. Drink eight glasses of fluid daily: Maintaining hydration is crucial in preventing sickle cell crises as it helps to keep the blood less viscous, reducing the risk of vaso-occlusion.
B. Maintain an updated haemophilus influenza type B immunization: While staying up to date on vaccinations is important, it is not specific to preventing sickle cell crises.
C. Assume postural drainage positions every 6 hr: This is more relevant for respiratory conditions like cystic fibrosis, not sickle cell anemia.
D. Avoid playground activities at school: Regular activity is beneficial, but avoiding extreme physical exertion is more relevant. Normal playground activities can usually be continued with proper hydration and caution.
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