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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "I will immediately report irregular respirations." Irregular respirations can be normal in infants, as their breathing patterns are often irregular. Immediate reporting is not typically necessary unless there are other signs of distress.

B. "I will immediately report a respiratory rate of 28." A respiratory rate of 28 is low for a 1-month-old infant, but immediate reporting depends on the overall clinical picture and other signs of distress. Normal respiratory rates for this age are usually between 30-60 breaths per minute.

C. "I will count the baby's respirations for 30 seconds and multiply by two." While this method is used for older children and adults, it’s not ideal for infants due to their irregular breathing patterns. Counting for a full minute provides a more accurate assessment.

D. "I will count the baby's respirations by observing abdominal movements." This is correct. In infants, respiration is primarily diaphragmatic, making abdominal movements a reliable indicator of respiratory rate.

A. The parent reports the child will not keep the arm elevated on the pillow. B. The fingers on the right hand have a capillary refill of 4 seconds. C. The fingertips of the right hand are swollen and bruised. D. The child is not attempting to move her right arm or fingers.

Correct Answer is B

Explanation

A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.

B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.

C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.

D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.

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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?

Nursing Test Bank

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