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    Ati Rn Paediatrics 2023 Proctored Exam

    A nurse is caring for an infant who weighs 7.8 kg (17.2 lb) and was admitted yesterday for treatment of moderate dehydration. Which of the following findings indicates to the nurse that the infant's condition is improving?

    Explanation & Rationale

    A. Respiratory rate 70/min: A respiratory rate of 70/min is high for an infant and may indicate ongoing respiratory distress or other issues. Normal respiratory rates for infants are generally 30-60 breaths per minute. This does not indicate improvement.B. Capillary refill is greater than 3 seconds. Capillary refill time greater than 3 seconds indicates poor perfusion, which can be a sign of continued dehydration or shock. This does not indicate improvement.C. Dry mucous membranes: Dry mucous membranes are a sign of dehydration. For an infant's condition to be improving, mucous membranes should be moist.D. Fontanelle is level and soft. A level and soft fontanelle indicates that the infant is likely well-hydrated. Sunken fontanelles are a sign of dehydration, so this finding suggests improvement in the infant’s hydration status.

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