Nokea
The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?
- A. Oliguria
- B. Weight loss
- C. Irritability and seizures
- D. Muscle weakness and cardiac dysrhythmias
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?
- A. Teaching how to irrigate the colostomy
- B. Protecting the skin around the colostomy
- C. Discussing the implications of a colostomy during puberty
- D. Using simple, straightforward language to prepare the child
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?
- A. Water excess
- B. Sodium excess
- C. Water depletion
- D. Potassium excess
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?
- A. Apply a urine collection bag to the perineal area.
- B. Tape a small medicine cup inside of the diaper.
- C. Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
- D. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A young mother asks if her 9-month-old can begin drinking cow's milk instead of formula. You explain that:
- A. Cow's milk is easier to digest than formula
- B. Breast milk or formula should be used for now because whole cow's milk is not recommended for infants under 1 year
- C. As long as whole milk is given and not skim milk, it is okay
- D. Cow's milk will decrease the chance of iron deficiency anemia
Correct Answer: B
Rationale: Breast milk or formula should be used for now because whole cow's milk is not recommended for infants under 1 year. Cow's milk is not suitable for infants under 1 year of age as it lacks essential nutrients like iron and can lead to iron deficiency. Therefore, it is important to continue with breast milk or formula to ensure the baby's nutritional needs are met. Choice A is incorrect as cow's milk is not easier to digest than formula for infants. Choice C is incorrect as the type of milk, whether whole or skim, is not the primary concern at this age. Choice D is incorrect as cow's milk can actually increase the risk of iron deficiency anemia in infants.