When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?

Fever and hypertension.

Increased specific gravity.

Tachypnea and tachycardia.

Bulging posterior fontanel.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.

Choice B rationale:

Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.

Choice C rationale:

Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.

Choice D rationale:

Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.

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Correct Answer is C

Explanation

Choice A rationale:

Exploring why the mother wants to hold the baby is important, but it does not directly address her immediate desire to hold her baby. Delaying the action could lead to emotional distress for the mother.

Choice B rationale:

Showing the mother how to lightly rub the baby's back above the suture line might be appropriate, but it doesn't fulfill the mother's wish to hold her baby. It also doesn't fully consider the sensitivity of the surgical site.

Choice C rationale:

Helping the mother hold the baby without placing pressure on the suture line is the most appropriate action. It addresses the mother's emotional needs while also considering the infant's post-operative condition.

Choice D rationale:

Reassuring the mother that she will be able to hold her baby in four to five days does not provide immediate comfort and support for her emotional distress. It's important to address her needs in the present moment.

A. The patient ties his shoelaces. B. The patient gives his first and last name. C. The patient can tell time. D. The patient draws a stick figure with six parts.

Correct Answer is D

Explanation

Choice A rationale:

The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.

Choice B rationale:

The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.

Choice C rationale:

The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.

Choice D rationale:

The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.

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When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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