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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatitis B (HBV): The Hepatitis B vaccine is typically completed in the infant stage, and a 5-year-old with up-to-date vaccinations would not need a booster for school entry. This is not included in the pre-kindergarten vaccine schedule.
B. Measles, mumps, and rubella (MMR): The MMR vaccine is part of the pre-kindergarten immunization schedule. A second dose is recommended between ages 4 and 6 to ensure immunity before school entry.
C. Haemophilus influenzae type B (Hib): The Hib vaccine is typically administered to infants and young children, and a 5-year-old with up-to-date immunizations would already be fully vaccinated against Hib. No booster is required at this age.
D. Pneumococcal conjugate vaccine (PCV): The PCV vaccine series is usually completed in infancy, and a 5-year-old with current vaccinations would not require a booster. This vaccine is not part of the pre-kindergarten schedule.
Correct Answer is A
Explanation
A. Defining a sense of self: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion," where individuals explore and form their own identity separate from their family and childhood roles.
B. Learning to perform tasks independently: This is more typical of early childhood (Erikson's "Autonomy vs. Shame and Doubt"). During this stage, children are learning basic independence, such as dressing and feeding themselves.
C. Learning to use creative energies: This task is more relevant to the preschool age group (Erikson's "Initiative vs. Guilt"), where children engage in imaginative play and begin exploring their own ideas and creativity.
D. Building a sense of trust: Building a sense of trust is the primary task in infancy (Erikson's "Trust vs. Mistrust"), where infants develop trust in their caregivers and the world around them.
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