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    RN Comprehensive predictor 2023 proctored exam

    A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor?

    Explanation & Rationale

    A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss. B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track. C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis. D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.

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