Maternal / Newborn Question #41

Question

An 8-month-old infant is admitted to the pediatric wing of the hospital with a diagnosis of pneumonia. Temperature is 103.4 °F rectally, and mother indicates the infant experienced 5 loose stools and three vomiting episodes along with respiratory congestion prior to admission. In addition to respiratory issues, the nurse suspects fluid imbalance because of which signs?

Answers

  1. Dry scaly skin, neck vein distention, and tearless crying.
    • Rationale:
  2. Bulging fontanels, low urine output, and thready pulses.
    • Rationale:
  3. Edema to feet, bounding pulses, bulging fontanels.
    • Rationale:
  4. Dry furrowed tongue, lethargy, and sunken eyes
    • Rationale:

Overview

Explanation

The answer is D. Fluid volume deficit is represented by dry furrowed tongue, lethargy, and sunken eyes and the infant has experienced vomiting and diarrhea. Options A, B, & C indicate inaccurate descriptions of fluid volume deficit. Bulging fontanels and bounding or neck vein distention are signs of hypervolemia/fluid volume excess.

Learning Outcomes

Test Taking Tip

Video Rationale