A 2-month-old infant with hypertrophic pyloric stenosis is receiving parenteral fluids for rehydration and decompression of the stomach while waiting for surgical repair. To maintain normal growth and development of the child during this period, which action should the nurse include in the plan of care?

Ensure placement of the nasogastric tube with an abdominal x-ray.

Use sterile water for gastric lavage.

Offer a pacifier for non-nutritive sucking.

Speak to the healthcare provider about instituting physical therapy.

Answer and Explanation

The Correct Answer is C

A. Ensuring the correct placement of the nasogastric tube with an abdominal x-ray is important for treatment but does not address the infant's developmental needs.

B. Using sterile water for gastric lavage may be necessary for stomach decompression but does not directly support the infant's growth and development.

C. Offering a pacifier for non-nutritive sucking provides comfort and helps maintain the infant’s sucking reflex, which is crucial for feeding and oral development.

D. Physical therapy is not relevant for a 2-month-old infant with hypertrophic pyloric stenosis and does not address immediate developmental needs.

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Correct Answer is B

Explanation

A. It is not necessary to keep the infant home from daycare unless the infant has a fever or other signs of illness.

B. Applying a cool pack to the injection site can help reduce discomfort and swelling.

C. Mild fever after vaccinations is common and not typically serious, but high or persistent fever should be reported.

D. Aspirin should not be given to children due to the risk of Reye's syndrome. Acetaminophen or ibuprofen (for infants older than 6 months) are safer alternatives for reducing fever and discomfort.

A. Pain management. B. Ambulation teaching. C. Leg elevation. D. Neurovascular checks.

Correct Answer is D

Explanation

A. Pain management is important but should follow the assessment of any immediate complications.

B. Ambulation teaching is important but is not the first priority immediately after cast application.

C. Leg elevation can help with swelling but is not the immediate priority.

D. Neurovascular checks are crucial to assess for complications such as compartment syndrome, which can occur after cast application. Early detection of neurovascular impairment is essential to prevent long-term damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

Correct Answer is B

Explanation

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?

Correct Answer is D

Explanation

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

The nurse is preparing a class about osteoporosis prevention. Which meal should the nurse recommend to the class?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is best for the nurse to implement?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.