The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Irritability and seizures. Water intoxication in infants is a serious condition that can occur when there is an excessive intake of fluids, leading to a dilution of electrolytes in the body. Infants are particularly vulnerable to water intoxication due to their small size and immature renal function. Irritability and seizures are suggestive clinical manifestations of water intoxication in infants. Irritability can be an early sign of cerebral edema, which can result from the shift of water into brain cells due to low electrolyte levels. Seizures can occur due to changes in brain function caused by electrolyte imbalances. Option A) Oliguria, is incorrect because oliguria refers to decreased urine output and is not typically seen in water intoxication where there is an excess of fluid intake. Option B) Weight loss is incorrect as water intoxication is characterized by fluid overload, leading to weight gain rather than weight loss. Option D) Muscle weakness and cardiac dysrhythmias are more commonly associated with electrolyte imbalances such as hyponatremia or hypokalemia, which can occur as a result of water intoxication, but they are not as specific to water intoxication as irritability and seizures. Educationally, it is crucial for nurses to be able to recognize the signs and symptoms of water intoxication in infants to prevent serious complications. Monitoring intake and output, as well as assessing for clinical manifestations like irritability and seizures, are essential nursing responsibilities in caring for infants receiving intravenous fluids.

Correct Answer: B

Rationale: Estimating output for a non-toilet trained child is crucial in pediatric nursing care to monitor fluid balance and assess for potential health issues. The correct answer is B) Weigh diapers after each void because it provides an indirect but accurate measure of urine output. By weighing the diapers before and after each void, healthcare providers can estimate the amount of urine produced by the child. Option A) Have parents estimate output, may not be reliable as parental estimations can vary widely and may not provide accurate measurements for clinical assessment. Option C) Placing a urine collection device on the child can be invasive, uncomfortable for the child, and may not be practical for continuous monitoring of output. Option D) Having the child sit on a potty chair 30 minutes after eating does not provide a method for accurately measuring output and may not be feasible for all children, especially those who are not toilet trained. In the context of pediatric nursing care, accurate measurement of urine output is essential for assessing hydration status, kidney function, and overall health of the child. Using the method of weighing diapers provides a non-invasive and practical way to estimate output in non-toilet trained children, ensuring effective monitoring and timely intervention when needed.

Correct Answer: A

Rationale: In this scenario, the correct intervention is to gently tap over the site (Option A) to increase the visibility of the superficial veins on the 2-year-old child. Tapping over the site can help dilate the veins and make them more prominent, facilitating successful venipuncture. Option B, applying a cold compress to the site, would cause vasoconstriction and make the veins less visible, hence it is incorrect. Option C, raising the extremity above the level of the body, may help with venous filling but may not necessarily increase vein visibility. Option D, using a rubber band as a tourniquet for 5 minutes, can lead to venous congestion, making it a potentially harmful choice for a young child. Educationally, understanding techniques to enhance vein visibility in pediatric patients is crucial for nurses administering intravenous therapy. Gentle tapping is a safe and effective method to aid in the visualization of veins, ensuring accurate and efficient IV placement, which is essential for delivering medications and fluids to pediatric patients.

Correct Answer: B

Rationale: In caring for a child with an intravenous (IV) infusion, the appropriate nursing action is to check the insertion site frequently for signs of infiltration (Option B). This is crucial because infiltration can lead to tissue damage, compromised medication delivery, and potential systemic effects. Regular assessment of the insertion site allows for early detection of infiltration, enabling prompt intervention to prevent complications. Changing the insertion site every 24 hours (Option A) is unnecessary and can increase the risk of infection and trauma to the child's delicate veins. Using a macrodropper to facilitate reaching the prescribed flow rate (Option C) is not directly related to monitoring the IV site for complications. Avoiding restraining the child to prevent undue emotional stress (Option D) is important for the child's emotional well-being but does not address the specific nursing action required for IV infusion care. Educationally, understanding the importance of monitoring IV sites in pediatric patients is crucial for nurses to provide safe and effective care. Teaching students the significance of early detection of complications like infiltration empowers them to deliver quality care and ensure positive outcomes for pediatric patients receiving IV therapy.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing action is option B: End the infusion and notify the practitioner. Rationale: - Ending the infusion is crucial to prevent further infiltration of the vesicant solution, which can cause tissue damage. - Notifying the practitioner is important because they need to assess the extent of the infiltration, provide further treatment if needed, and potentially order a different course of action. Why Others Are Wrong: - Option A: Applying ice is not recommended for a vesicant infiltration as it can further damage the tissues. - Option C: Slowing the infusion rate does not address the immediate issue of the infiltration of the vesicant solution. - Option D: Applying warm compresses is also not appropriate for a vesicant infiltration and can potentially worsen the tissue damage. Educational Context: Understanding the appropriate response to an IV infiltration, especially when dealing with vesicant solutions, is crucial for pediatric nurses. Prompt action can prevent serious complications and ensure the child's safety and well-being. Nurses must be knowledgeable about IV therapy complications and interventions to provide optimal care for pediatric patients.