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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Related Questions
Correct Answer is A
Explanation
A. Rotavirus: The rotavirus vaccine is recommended for infants at 2, 4, and possibly 6 months of age, depending on the vaccine formulation. It helps protect against rotavirus, which can cause severe diarrhea and dehydration in infants.
B. Measles, mumps, rubella (MMR): The MMR vaccine is not given until 12-15 months of age. It is not part of the vaccination schedule for a 4-month-old infant.
C. Varicella (VAR): The varicella vaccine is typically administered at 12-15 months of age. It is not appropriate for a 4-month-old infant.
D. Influenza: The influenza vaccine is recommended annually starting at 6 months of age. A 4-month-old is too young to receive the influenza vaccine.
Correct Answer is A
Explanation
A. Ask the child what he knows about the procedure. Understanding the child’s knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety. This is the first step in providing appropriate and effective education.
B. Allow the child to see and touch IV tubing and supplies. Familiarizing the child with the equipment can reduce fear, but it is better to first assess what the child knows and address any concerns or fears before showing the supplies.
C. Describe the procedure using visual aids. Using visual aids to explain the procedure is helpful, but it should follow assessing the child’s current understanding to ensure the explanation is appropriate and comprehensive.
D. Explain to the child's parents what role they will have during the procedure. Involving the parents and explaining their role is important, but the child’s understanding and comfort should be addressed first to ensure they are calm and prepared for the procedure.
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