Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
An infant who has a 2-day history of vomiting and an elevated temperatureA nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Correct answer
D
Rationale
The correct answer is D: Body weight. Body weight is the most reliable indicator of fluid loss in infants because weight changes directly reflect changes in fluid balance. As the infant loses fluids through vomiting and fever, there will be a decrease in body weight due to dehydration. Monitoring body weight provides a quantitative measure of fluid loss and guides the nurse in assessing the severity of dehydration and determining the appropriate interventions.
Blood pressure (A), respiratory rate (B), and skin integrity (C) can be affected by various factors other than fluid loss in infants and may not accurately reflect the extent of dehydration. Blood pressure can be maintained until severe dehydration occurs, respiratory rate may increase due to fever or infection, and skin integrity changes may not be specific to fluid loss in this situation.
Therefore, body weight is the most reliable indicator as it directly reflects changes in fluid balance, making it crucial in managing dehydration in infants.
Blood pressure (A), respiratory rate (B), and skin integrity (C) can be affected by various factors other than fluid loss in infants and may not accurately reflect the extent of dehydration. Blood pressure can be maintained until severe dehydration occurs, respiratory rate may increase due to fever or infection, and skin integrity changes may not be specific to fluid loss in this situation.
Therefore, body weight is the most reliable indicator as it directly reflects changes in fluid balance, making it crucial in managing dehydration in infants.