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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintaining strict intake and output is crucial in managing septic shock as it helps to monitor fluid balance, which is essential for managing hypovolemia and ensuring adequate perfusion.
B. While assessing warmth of extremities is important, it is not as directly related to the immediate management of septic shock as monitoring intake and output.
C. Monitoring blood glucose levels is important, especially in septic patients, but it is not the primary focus in the initial management of septic shock.
D. Keeping the head of the bed raised 45 degrees can help with breathing but is not the most critical intervention in the immediate management of septic shock.
Correct Answer is D
Explanation
A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.
B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.
C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.
D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.
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