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 D
Explanation
A. ``It's okay for my child to have plenty of ice cream.": While ice cream is soft and soothing, it may increase mucus production. Dairy products are contraindicated post tonsillectomy.
B. "I'll help my child gargle with salt water a few times a day.": Gargling is contraindicated post-tonsillectomy because it can dislodge clots and increase the risk of bleeding.
C. "It's okay for my child to ride his bike in a few days.": Strenuous activity should be avoided to reduce the risk of bleeding.
D. "I'll call the doctor if my child is swallowing continuously.": Continuous swallowing can indicate bleeding, a serious complication that requires immediate medical attention.
Correct Answer is D
Explanation
A. A school-age child who cries when the nurse is giving him an injection: Crying during an injection is a normal reaction for a child and does not indicate abuse.
B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruises on the shins are common in toddlers due to normal play and falls. Without other concerning signs, this does not strongly indicate abuse.
C. A preschooler who has a BMI indicating obesity: While childhood obesity can be a sign of neglect in some cases, it is not a specific or immediate indicator of abuse without other signs.
D. An adolescent who asks to stay in the hospital because he likes the room: This is concerning because it might indicate that the adolescent is not feeling safe or comfortable at home, which could be a sign of abuse or neglect.
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