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 A
Explanation
A. "Bring your infant into the clinic today to be seen." This is the appropriate response. Projectile vomiting can be a sign of pyloric stenosis, a condition that requires prompt medical evaluation and potential surgical intervention.
B. "You might want to try switching to a different formula." While switching formula might be considered for minor feeding issues, projectile vomiting is severe and warrants immediate medical attention rather than a dietary change.
C. "Give your infant an oral rehydration solution." Oral rehydration might be useful for dehydration, but it does not address the underlying cause of projectile vomiting, which needs to be diagnosed and treated by a healthcare professional.
D. "Burp your child more frequently during feedings." Although burping can help with mild spit-ups, projectile vomiting is a more serious symptom that requires medical evaluation rather than just a change in feeding practices.
Correct Answer is C
Explanation
A. Restrain the child's arms. Restraining the child's arms is unsafe and can cause injury. It is important to allow the seizure to occur without interference, except to ensure the child’s safety.
B. Insert a padded tongue blade into the child's mouth. This is an outdated and incorrect practice. Inserting anything into a seizing child's mouth can cause injury to the mouth or teeth and poses a choking hazard.
C. Place the child in a side-lying position. This is the correct action as it helps maintain an open airway and allows for drainage of saliva or vomit, reducing the risk of aspiration.
D. Elevate the child's legs on a pillow. This is not an appropriate action during a seizure as it does not address the safety and airway management needs of the child. Keeping the child on their side is more important for airway safety.
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