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 A
Explanation
In this situation, the practical nurse (PN) should coach the client to take slow, deep breaths during each contraction. The client has already been medicated with butorphanol and promethazine for pain relief and it may not be appropriate to administer another dose at this time. Instead, the PN can provide non- pharmacological pain relief measures such as coaching the client to use breathing techniques to help manage the pain during contractions. The other actions listed may also be appropriate in some situations, but coaching the client to use breathing techniques is the most appropriate action in this situation.
Correct Answer is B
Explanation
Based on the assessment findings, the infant is at the greatest risk for developing anemia due to a lack of iron. Infants should begin eating solid foods that are rich in iron at around 6 months of age to ensure they are getting enough of this important nutrient. Drinking whole milk from a bottle can displace other foods that are rich in iron and contribute to the development of anemia.
Option A, allergies related to whole milk, is a possibility but not the greatest risk in this situation.
Option C, obesity due to increased calorie count, is also a possibility but not the greatest risk.
Option D, lactose intolerance due to whole milk, is a possibility but not the greatest risk in this situation.
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