A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?
Plan for nurses to provide the feedings.
Report this finding to the health care provider.
Assure the mother that this is a normal finding.
Tell the mother it is all right to feel anxious.
The Correct Answer is B
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Painful joints are not a common side effect of prednisone. Prednisone can cause musculoskeletal issues, but painful joints are not a prominent manifestation.
Choice B rationale:
A decrease in appetite is a possible side effect of prednisone. However, it's not the focus of this question, as other choices are more relevant.
Choice C rationale:
A yellow tinge to the whites of the eyes (jaundice) is not a commonly associated side effect of prednisone. Jaundice is usually linked to liver dysfunction or other conditions affecting bilirubin metabolism.
Choice D rationale:
A round face, often referred to as "moon face,”. is a well-recognized side effect of prednisone. It occurs due to fluid retention and fat redistribution, leading to a characteristic facial appearance.
Correct Answer is C
Explanation
Choice A rationale:
Administering a bolus of intravenous (IV) fluids might be necessary for severe dehydration, but in mild dehydration, oral rehydration is preferred as it avoids potential complications associated with IV fluids.
Choice B rationale:
Offering clear fluids, popsicles, and gelatin is appropriate, but this choice does not specifically address rehydration, which is the primary concern in mild dehydration.
Choice C rationale:
Offering oral rehydration solution (ORS) in small, frequent amounts is the most appropriate intervention for mild dehydration secondary to diarrhea. ORS contains the right balance of electrolytes and fluids to rehydrate without overwhelming the gastrointestinal tract.
Choice D rationale:
Keeping the child on a strict BRAT diet (bananas, rice, applesauce, toast) is an outdated approach. While BRAT foods can be tolerated during mild illness, they lack the necessary electrolytes and fluids to effectively rehydrate.
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