which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?

Correct answer: B

Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.

2. What is the best indicator of fluid balance in a pediatric patient?

Correct answer: C

Rationale: Weight is the most accurate indicator of fluid balance in pediatric patients. Changes in weight reflect shifts in body fluid levels more directly compared to other parameters. Blood pressure and heart rate may be affected by various factors other than fluid balance. While urine output is important in assessing renal function, it may not provide a comprehensive picture of overall fluid balance in pediatric patients.

3. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant’s crib. What is the most appropriate response for the nurse to make?

Correct answer: D

Rationale: Encouraging the baby to fall asleep in the crib while still awake can help establish healthy sleep habits and reduce night waking.

4. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?

Correct answer: A

Rationale: The American Academy of Pediatrics recommends limiting fruit juice intake to no more than 4 oz per day for infants, as excessive juice can contribute to poor nutrition and dental issues.

5. During an otoscopic examination on an infant, in which direction is the pinna pulled?

Correct answer: C

Rationale: For infants, the pinna is pulled down and back to straighten the ear canal and allow proper visualization of the tympanic membrane during otoscopic examination.

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