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Dehydration Hesi Case study
What assessment findings will lead the nurse to believe an infant is moderately dehydrated? A. Rectal temperature of 99°F (37.2°C), heart rate (HR) of 120 beats/minute, and a respiratory rate of 28 breaths/minute. B. A sunken fontanel, dry mucous membranes, and HR of 160 beats/minute. C. Warm skin, rectal temperature of 100°F (37.8°C), and blood pressure 100/ mmHg. D. Two wet diapers within the past 8 hours, +3 edema of feet, and a respiratory rate of 30 breaths/minute. - ANSWER-ANSWER (s): B Rational:
- Common signs of dehydration in infants include a sunken fontanel, slow capillary refill, dry mucous membranes, poor skin turgor, pale color, decreased urinary output, normal to low blood pressure, and normal to high heart rate.
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.) A. "Do you have any other children?" B. "Have you offered fluids other than formula?" C. "What was the client's last weight?" D. "Has the client completed all their immunizations?" E. "How many hours does the client normally sleep each day?" - ANSWER- ANSWER (s): B, C Rational:
- If the infant is not taking formula, clear liquid replacement fluids can help to maintain hydration.
- Weight is the most important determinant in fluid loss. The nurse needs baseline data to compare to infants current condition inorder to determine hydration status. Lab Values
D. Sodium chloride 0.9% as 100 mL bolus over 20 minutes - ANSWER-ANSWER (s): D Rational: Dextrose is contraindicated in the early treatment stages of rehydration. Fluid replacement for dehydration begins with a fluid bolus of sodium chloride 0.9% using the formula 20 mL/kg over 20 minutes The infant weighs 14 pounds. The HCP prescribes an IV infusion of sodium chloride 0.9% to be infused at 8mL/kg/hr. How many milliliters of the prescribed solution should the nurse infuse each hour? - ANSWER-ANSWER (s): 51 mL Rational: 14 lbs / 2.2 = 6.36 kg 6.36 kg x 8 = 50.88 mL/ hr round to 51 mL/ hr Infant formula is 20 kcal per oz and the infant consumes 4 oz every 4 hrs. How many kcal per day is the infant consuming>? - ANSWER-ANSWER (s): 480 kcal Rational:
- 24 hrs / 4 hrs = 6 feeds per day
- 4oz x 6 = 24 oz of total formula consumed in a day
- 24 oz x 20 = 480 kcal Which intervention is BEST for the nurse to delegate to the practical nurse? A. Gather equipment and star IV fluids B. Place a urine bag on the infant to collect a urine specimen C. Perform the venipuncture for lab specimens D. Start the care plan for the client and family - ANSWER-ANSWER (s):B. Rational: This the only listed intervention that is within the scope of the PN's role. Which is the MOST reliable indicator for fluid loss in the pediatric client? A. Daily assessment of skin turgor
C. 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 D. "Please wait outside until the procedure is finished." - ANSWER-ANSWER (s): C Rational: This is honestly just common sense Scenario: During the hourly rounds, the nurse notices that the intravenous fluids (IVF) did not infuse at the prescribed rate. Question: What should be the nurse's INITIAL intervention? A. Double the fluid rate for 20 minutes until the correct amount of fluid is received. B. Notify the HCP immediately. C. Assess the IV site for signs of infiltration. D. Offer the infant oral fluids to account for the fluids he didn't receive via IV. - ANSWER-ANSWER (s): C
Rational: Assessment is the first step in the nursing process. Taking an assessment will help identify if the malfunction was due to the equipment or procedure Based on the nurse's knowledge of growth and development, which is the best play intervention for a 7-month-old? A. Colored blocks B. Bright dangling mobile C. Ball D. Stuffed animal - ANSWER-ANSWER (s): A Rational: At 7-months-old, the infant should have fine motor skills to grasp, hold, and manipulate objects, transfer objects from hand to hand, bang objects together, and release objects. He should be able to imitate actions and noises. Colored blocks provide the ability to use gross motor skills. Which developmental milestones should be accomplished by a 7-month-old infant? Select all that apply
C. PCV (pneumococcal) D. MMR (measles mumps rubella). E. Varicella. - ANSWER-ANSWER (s): A, B, C Rational: The CDC recommends that a 7 month old already have their hep b, DTaP and PCV vaccine.
- The first MMR and varicella vaccine is given between 12 to 15 months Which are the best muscles to use for multiple intramuscular injections (IM) for a 7 - month-old infant, based on the principles of growth and development? A. Ventrogluteal and dorsogluteal. B. Vastus lateralis and ventrogluteal. C. Deltoid and dorsogluteal. D. Deltoid and vastus lateralis. - ANSWER-ANSWER (s): B
Rational: The vastus lateralis is the preferred site for intramuscular injections because it is the largest muscle mass in children younger than 3-years-old. If this is not possible, the vetrogluteal muscle can also be used. Following the administration of the client's vaccinations, the nurse continues to educate the family regarding safety measures. Which safety measures should the nurse teach the family? A. Freely sprinkle baby powder on skin after bathing to keep the skin moist. B. Offer a bottle of juice at bedtime to keep the child full during the night. C. Position on the right side or the left side for napping. D. Place in the backseat in a rear-facing car seat when traveling. - ANSWER- ANSWER (s): D. Rational: Infants who are 7-months-old should be rear-facing. Car seats are approved based on weight and height; however, the American Academy of Pediatrics recommends that all children remain rear-facing until at least 2-years-old.
The couple depart from the hospital, and the nurse notices the infant's caregiver is teary-eyed and staring out the window. The infant is crying, but the caregiver does not make any attempt to console the infant. Question: Which statement is MOST therapeutic by the nurse? A. "I will not disturb you now. I will be back later." B. "I think you are emotional because you are tired and need to rest." C. "I can see that you are upset. Would you like to talk?" D. "I am going to call the Chaplain so you can talk." - ANSWER-ANSWER (s): C Rational: The statement acknowledges the caregiver display of emotion and offers the opportunity to discuss the situation. Scenario: The infant's caregiver is unemployed, has limited work skills, and has no family in the immediate area. The caregiver has not eaten much in the past few days.
Question: As an advocate for the infant and caregiver, which is the BEST consult for the nurse to initiate at this time? A. Child Life Specialist (CLS). B. Dietician. C. Social worker. D. Pediatric Nurse Practitioner (PNP). - ANSWER-ANSWER (s): C Rational: The social worker monitors the emotional, behavioral, and educational development of the child and will provide intervention to the infant or caregiver as needed. The nurse orders a meal tray for the caregiver. Based on the nurse's knowledge that the caregiver follows a vegan diet, which food should be excluded from the tray? A. Rice
What does the pediatric nurse understand as the gold standard for verification of the NGT placement? A. Aspiration B. X-ray C. pH testing D. Ascultation - ANSWER-ANSWER (s): B Rational: The tube can be visualized in the correct anatomical location. Based on the 2012 safety alert issued by the Child Health Patient Safety Organization, which method for NGT placement verification is no longer recommended? A. pH testing B. X-ray C. Aspiration
D. Auscultation - ANSWER-ANSWER (s): D Rational: This is a subjective method, and the nurse should rely on objective methods. The nurse knows that the average 7-month-old needs around 100 kcal/kg for daily caloric intake. Regular infant formula contains 20 kcal/ounce. What is the daily recommended requirement of formula, in ounces, for an infant who weighs 14 lbs? - ANSWER-ANSWER (s): 32 kcal Rational:
- 14 lbs / 2.2 = 6.36 kg
- 6.36 kg x 100 kcal = 636 total kcal needed per day Formula contains 20 kcal /oz
- 636 kcal / 20 kcal = 32
