This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding.
He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home.
Review H and P and flow sheet.
Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply.
Temperature 103 °F (39.4 °C)
Blood pressure 89/51 mmHg
Respiratory rate 55 breaths/min
Copious, clear secretions from both nostrils
Oxygen saturation 95%
Wet diaper with 12 mL of urine
Heart rate 159 bpm
Correct Answer : A,C,D,E
Fever increases fluid loss through perspiration.
Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.
High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.
The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.
Oxygen saturation within the normal range does not indicate increased fluid requirements.
Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.
Heart rate alone does not indicate increased fluid requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.
Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.
The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.
The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.
The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.
Correct Answer is D
Explanation
Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.
Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.
Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.
Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.
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