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1. Which assessment findings will lead the nurse to believe an infant is
moderately dehydrated?
ANSWERS: A sunken fontanel, dry mucous membranes, and HR of 160
beats/minute.
2. To obtain more information about the client's current status, which
questions are a priority for the nurse to ask family? (Select all that apply.
One, some, or all options may be correct.)
ANSWERS: "Have you offered fluids other than
formula?" "What was the client's last weight?"
4. Which intravenous fluids does the nurse anticipate for initial
rehydration?
ANSWERS: Sodium chloride 0.9% as 100 mL bolus over 20 minutes.
5. The infant weighs 14 pounds. The healthcare provider (HCP)
prescribes an IV infusion of sodium chloride 0.9% to be infused at 8
mL/kg/hr. How many milliliters of the prescribed solution should the
nurse infuse each
hour? (Enter numerical value only. If rounding is necessary, round to
the nearest whole number.)
ANSWERS: 51
, 6. Infant formula is 20 calories per ounce and the caregiver states that the
infant consumes 4 ounces every 4 hours. How many calories per day is
the infant consuming? (Enter numeric value only. If rounding is necessary,
round to the nearest whole number.)
ANSWERS: 480
7. Which intervention is best for the nurse to delegate to the practical
nurse (PN)?
ANSWERS: Place a urine bag on the infant to collect a urine specimen.
8. Which is the most reliable indicator for fluid loss in the pediatric client?
ANSWERS: Daily weights at the same time each morning.
After 3 hours, the infant still has no urine output. The healthcare provider
(HCP) prescribes an in-and-out catheterization to obtain a urine
specimen. The nurse explains the procedure to the caregiver who begins
to cry, stating the healthcare team is causing the child harm.
9. What is the best response by the nurse?
ANSWERS: "This procedure is important to make the best medical decisions
for the infant. It may be uncomfortable, but it will not cause any long term
effects."
During the hourly rounds, the nurse notices that the intravenous fluids
(IVF) did not infuse at the prescribed rate.
10. What should be the nurse's initial intervention?
ANSWERS: Assess the IV site for signs of infiltration.