Test-Taking Tip

Consider which nursing diagnosis is the most life-threatening to identify the nurse's top priority. Infants are particularly susceptible to fluid imbalances and can become seriously compromised because of health conditions and treatments that affect fluid status.

Content Area: Child Health, Hematological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems

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Health Promotion and Maintenance

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Answer 1 is incorrect because, although elevated body temperature is a concern during phototherapy treatment, the main complication of elevated temperature is dehydration, making fluid volume deficiency the highest priority. Answer 2 is incorrect because a change in stooling patterns is expected as the body eliminates the bilirubin and is not of concern. Answer 3 is correct because an infant with hyperbilirubinemia will have increased fluid needs due to increased insensible fluid losses from phototherapy treatment and increased fluid losses resulting from loose stools as the bilirubin is eliminated through the bowels. Failure to monitor and treat potential fluid volume imbalances can quickly put the infant at risk for dehydration. Answer 4 is incorrect because a diagnosis of interrupted family processes is not the highest priority for maintaining physiological integrity.

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