A 3-week-old infant is admited to the pediatric unit with vomiting and dehydration. The mother describes the infant as having projectile vomiting after eating. She also tells the practical nurse (PN) that the baby is always hungry. Which finding warrants immediate intervention by the PN?
Hyperactive gastric sounds.
Irregular palpable pulse.
Crying without tears.
Underweight for age.
The Correct Answer is B
This finding may indicate a potential cardiac issue that needs immediate medical atention. Projectile vomiting and excessive hunger in a young infant may be signs of pyloric stenosis, a condition in which the muscle between the stomach and small intestine thickens, making it difficult for food to pass through.
Hyperactive gastric sounds may be present with vomiting, but it is not an immediate concern.
Crying without tears may be a sign of dehydration, but it is not an immediate concern.
Underweight for age is a concern but it is not a finding that requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The first intervention the PN should implement is to **sit and offer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Offering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.
Correct Answer is A
Explanation
Newborns have a stump of the umbilical cord attached to their belly button which eventually falls off within 1-2 weeks. During this time, it is important to keep the area clean and dry to prevent infection. The PN should instruct the parents to clean the area with water and a clean cloth or cotton swab, and then gently pat the area dry with a clean towel. The parents should also be advised to avoid using any harsh soaps, lotions, or alcohol on the cord stump, as this can cause irritation or delay the healing process. It is not recommended to cover the cord stump with a sterile dressing unless specifically instructed to do so by a healthcare provider.
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