1. A toddler has a two-day history of vomiting and diarrhea. Which of the following
should the nurse immediately report of the provider?
A- BP 68/40
B-dry mucous membranes
C- decreases urinary output
D- Temperature 38.9 C (102F): A-
a toddler has a history of fluid loss and the nurse should put priority on the possibility of
impending shock. In infants and young children, hypotension, is usually a late sing of
dehydration and be warning of cardiovascular collapse.
2. A nurse an Asthma Action Plan with a school aged child. Which actions should the
client take when symptoms are in the yellow zone?
A- Drink cold fluids
B- Take the rescue medication
C- Continue to normal activities
D- Go to the ED: B-
The Yellow Zone means caution. The child should use the a quick- relief medication to
prevent an asthma attack from getting worse. Indications of yellow zone: peak flow
numbers 50% to 80% of best peak flow, cough, wheeze, tight chest, and wakes during the
night.
3. A nurse teaches a parent who to successfully feed an infant who has an unrepaired
cleft lip and palate. Which of the following instructions should the nurse include?
(select all)
A- Observe forehead for a wrinkled brow
B- Use a low calorie formula for feedings
C- Burp frequently, after every oz of fluid
D- Hold in an upright position during feedings
E- Use a special feeder with a slit cup tip nipple: A, C, D, E-
Observe for a facial sign, which is an indication the infant should stop feeding for a brief
period. Burp after every oz of fluid or 2-3 times during a feeding. People with cleft lips
swallow a lot of air. Hold in an upright position, facilities gravity to allow fluid to be
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