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 A

Explanation

A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.

B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.

C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.

D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.

A. "Bring your infant into the clinic today to be seen." B. "You might want to try switching to a different formula." C. "Give your infant an oral rehydration solution." D. "Burp your child more frequently during feedings."

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.

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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

Naxlex Comprehensive Predictor Exams

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