A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?
Alert and responsive to stimuli
Skin warm and dry and tone is appropriate for ethnicity
Abdomen distended with visible mass noted in right upper quadrant
Full range of motion in extremities, no clicks noted
The Correct Answer is C
Choice A reason: This statement is normal, as an infant who is 2 months old should be alert and responsive to stimuli. The nurse should assess the infant's level of consciousness and responsiveness using the AVPU scale (alert, voice, pain, unresponsive).
Choice B reason: This statement is normal, as an infant who is 2 months old should have warm and dry skin and a tone that is appropriate for their ethnicity. The nurse should assess the infant's skin color, temperature, moisture, and turgor.
Choice C reason: This statement is abnormal, as an infant who is 2 months old should not have a distended abdomen or a visible mass in the right upper quadrant. This could indicate a serious condition such as a liver tumor, a bowel obstruction, or a hernia. The nurse should report this finding to the provider and monitor the infant for signs of pain, vomiting, or jaundice.
Choice D reason: This statement is normal, as an infant who is 2 months old should have full range of motion in their extremities and no clicks noted. The nurse should assess the infant's muscle strength, tone, and symmetry, and check for any signs of hip dysplasia, such as a positive Barlow or Ortolani test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The child has signs of dehydration and hypovolemic shock, such as vomiting, melena, abdominal pain, and weak pedal pulses. Dehydration is a loss of fluid and electrolytes from the body, which can result from gastroenteritis. Hypovolemic shock is a life-threatening condition that occurs when the blood volume is too low to maintain adequate perfusion and oxygen delivery to the vital organs.
Choice B reason: The child does not have signs of peritonitis and septic shock, such as fever, chills, rigors, tachycardia, hypotension, and abdominal rigidity. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity and organs. Septic shock is a severe infection that causes systemic inflammatory response syndrome and organ dysfunction.
Choice C reason: The child does not have signs of pancreatitis and cardiogenic shock, such as elevated serum amylase and lipase, jaundice, dyspnea, crackles, and chest pain. Pancreatitis is an inflammation of the pancreas, an organ that produces digestive enzymes and hormones. Cardiogenic shock is a failure of the heart to pump enough blood to meet the body's needs.
Choice D reason: The child does not have signs of peptic ulcer and anaphylactic shock, such as hematemesis, dyspepsia, urticaria, angioedema, and wheezes. Peptic ulcer is a sore in the lining of the stomach or duodenum, caused by factors such as Helicobacter pylori infection, NSAIDs, or stress. Anaphylactic shock is a severe allergic reaction that causes bronchoconstriction, vasodilation, and hypotension.
Correct Answer is B
Explanation
Choice A reason: Skin integrity is not a reliable indicator of fluid loss, as it can be affected by other factors such as infection, trauma, or allergy. Skin integrity can be assessed by checking for turgor, elasticity, and color.
Choice B reason: Body weight is a reliable indicator of fluid loss, as it reflects the amount of water and electrolytes in the body. Body weight can be measured by using a calibrated scale and comparing it with the previous or baseline weight.
Choice C reason: Blood pressure is not a reliable indicator of fluid loss, as it can be influenced by other factors such as cardiac output, vascular resistance, and stress. Blood pressure can be measured by using a sphygmomanometer and a stethoscope.
Choice D reason: Respiratory rate is not a reliable indicator of fluid loss, as it can be affected by other factors such as oxygen demand, lung function, and airway obstruction. Respiratory rate can be measured by counting the number of breaths per minute.
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