A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Respiratory rate 24/min>
Urine specific gravity 1.015
Heart rate 130/min
Capillary refill greater than 3 seconds
The Correct Answer is B
A. Respiratory rate 24/min: While a normal respiratory rate is positive, it is not a primary marker of hydration status.
B. Urine specific gravity 1.015: A normal urine specific gravity indicates adequate hydration.
C. Heart rate 130/min: Tachycardia indicates ongoing dehydration or stress.
D. Capillary refill greater than 3 seconds: Prolonged capillary refill suggests inadequate perfusion and continued dehydration.
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Related Questions
Correct Answer is D
Explanation
A. Counting the number of wet diapers every shift: While useful, daily weight provides a more precise measure of fluid balance.
B. Taking the infant's vital signs every 2 hr: Vital signs alone do not provide as direct a measure of fluid balance as daily weight.
C. Measuring the infant's head circumference twice per day: Head circumference is unrelated to hydration status.
D. Weighing the infant at the same time every day: Daily weight is the most accurate indicator of fluid status in infants.
Correct Answer is C
Explanation
A. Jaundice: Jaundice is not associated with intussusception.
B. Drooling: Drooling is not a sign of intussusception.
C. Mucus in stools: Intussusception can cause "currant jelly stools," which are stools with mucus and blood due to intestinal obstruction.
D. Increased appetite: Children with intussusception typically have decreased appetite and may experience vomiting.
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