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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The screening test that should be scheduled for a client who is gravida 4 para 3 at 16-weeks gestation is **Maternal serum alpha-feto protein (MSAFP)**. Second trimester prenatal screening may include several blood tests, called multiple markers. These markers provide information about a woman's risk of having a baby with certain genetic conditions or birth defects. Screening is usually done by taking a sample of the mother's blood between the 15th and 20th weeks of pregnancy (16th to 18th is ideal)².

A. Flaring of the nares. B. Resting respiratory rate of 35 breaths/minute. C. Bilateral bronchial breath sounds. D. Diaphragmatic respirations.

Correct Answer is A

Explanation

Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.

A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following the prenatal clinic's screening protocol, the practical nurse (PN) is preparing laboratory prescriptions for clients who are scheduled to be seen today. Which screening test should be scheduled for a client who is gravida 4 para 3 at 16-weeks gestation?

Correct Answer is A

Explanation

A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for a postpartum client who delivered 5 hours ago and has saturated a perineal pad with a few clots within 15 minutes. Which action is most important for the PN to implement?

The practical nurse (PN) is assisting with the admission of a 12-month-old child with a history of frequent colds and growth failure. Testing is being planned for a possible diagnosis of cystic fibrosis (CF). Which information is most important for the PN to obtain?

The parents of a child with acute glomerulonephritis are describing to the practical nurse (PN) what originally motivated them to seek medical care. Which sign did the child most likely exhibit?

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