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. Parents would suspect hearing loss if their child did not:

Correct answer: D

Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.

3. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

Correct answer: A

Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.

4. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What nursing goal is appropriate for this child?

Correct answer: C

Rationale: Prednisone, an immunosuppressant, increases the child's susceptibility to infections, making infection prevention a critical nursing goal. Detecting edema and stimulating appetite are important but secondary to preventing potentially life-threatening infections.

5. Which disease requires strict isolation due to its mode of transmission?

Correct answer: B

Rationale: The correct answer is Chickenpox (choice B). Chickenpox is highly communicable and requires strict isolation to prevent the spread of the virus through direct contact, droplet transmission, and contaminated objects. Mumps (choice A) is also contagious but does not typically require strict isolation. Exanthema subitum (roseola) (choice C) and Erythema infectiosum (fifth disease) (choice D) are not as highly contagious as chickenpox and do not necessitate strict isolation.

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