A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

Slow respirations

Capillary refill 3 seconds

Sunken fontanels

Increased blood pressure

Answer and Explanation

The Correct Answer is C

A. Slow respirations:
Infants with dehydration often have tachypnea, not slow respirations.

B. Capillary refill 3 seconds:
A refill time greater than 2 seconds can be abnormal, but 3 seconds is borderline and not specific to severe dehydration.

C. Sunken fontanels:
Sunken anterior fontanel is a key sign of severe dehydration in infants due to fluid volume loss.

D. Increased blood pressure:
Blood pressure is usually low or normal in severe dehydration; hypotension may indicate shock.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Aim the stream of water directly at the cerumen impaction:
This may injure the tympanic membrane. Irrigation should be directed at the superior wall of the canal.

B. Use cool water to flush the cerumen from the ear canal:
Cool water can cause dizziness or nausea due to stimulation of the vestibular system. Body-temperature water is preferred.

C. Instill cerumen-softening drops before the irrigation:
Softening the cerumen (e.g., with mineral oil or hydrogen peroxide solution) makes irrigation more effective and comfortable.

D. Remind the client to use a cotton swab periodically to remove cerumen:
Cotton swabs can push cerumen deeper and risk damage to the ear canal or drum.

A. Place the newborn on a flat surface and clap hands loudly. B. Stroke the newborn's cheek toward their mouth. C. Stroke upward on the lateral aspect of the newborn's foot. D. Place the newborn on their abdomen and observe the movement of their extremities.

Correct Answer is A

Explanation

A. Place the newborn on a flat surface and clap hands loudly:
A sudden loud noise or movement causes the newborn to extend and abduct arms, then adduct them – the Moro (startle) reflex.

B. Stroke the newborn's cheek toward their mouth:
This tests the rooting reflex, not the Moro reflex.

C. Stroke upward on the lateral aspect of the newborn's foot:
This elicits the Babinski reflex, not Moro.

D. Place the newborn on their abdomen and observe the movement of their extremities:
This would assess gross motor tone or posture, not the Moro reflex.

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A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an irrigation to remove a buildup of cerumen from a client's ear. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is A

Explanation

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