A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first?
Initiate a prescribed IV for parenteral fluid.
Feed the infant 3 ounces of Isomil.
Give the infant 5% dextrose in water orally.
Insert a nasogastric tube for feeding.
The Correct Answer is A
The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.
Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.
Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.
The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Explanation
Course breath sounds - Respiratory Distress
Decreased level of consciousness - Cerebral Edema
Seizure activity - Cerebral Edema
Irritability - Both (Can be associated with both cerebral edema and respiratory distress)
Bradycardia - Cerebral Edema
Rationale:
Course breath sounds - Respiratory Distress
Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.
Decreased level of consciousness - Cerebral Edema
A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.
Seizure activity - Cerebral Edema
Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.
Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.
Bradycardia - Cerebral Edema
Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.
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