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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A 13% weight loss is a sign of severe dehydration in infants. Dehydration occurs when the body loses more fluid than it takes in. Acute gastroenteritis can cause vomiting and diarrhea, which can lead to fluid loss and dehydration.

Choice B reason: A bulging anterior fontanel is not a sign of dehydration, but rather a sign of increased intracranial pressure. The anterior fontanel is the soft spot on the top of the infant's head. It should be flat or slightly concave, not bulging or sunken.

Choice C reason: Bradypnea is not a sign of dehydration, but rather a sign of respiratory depression. Bradypnea is abnormally slow breathing, usually less than 12 breaths per minute in infants. Dehydration can cause tachypnea, which is abnormally fast breathing, usually more than 60 breaths per minute in infants.

Choice D reason: A capillary refill of 3 seconds is not a sign of dehydration, but rather a sign of normal perfusion. Capillary refill is the time it takes for the color to return to the nail bed after pressing on it. A normal capillary refill is less than 2 seconds. Dehydration can cause delayed capillary refill, which is more than 2 seconds.

A. Half-strength infant formula B. Half-strength orange juice C. Sterile water D. Oral electrolyte solution

Correct Answer is D

Explanation

Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.

Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.

Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.

Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.

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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?

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