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A nurse in an emergency department is caring for an infant.

Exhibits

The nurse on the pediatric unit is reviewing the infant's medical record immediately after receiving report from the emergency department nurse. Which of the following information requires immediate follow-up? Select all that apply.

Intake and output

Heart rate

Respiratory rate

Bowel sounds

Mucous membranes

Weight

Retractions

Lung sounds

Temperature

Oxygen saturation

Answer and Explanation

Correct Answer : A,B,C,G,H,I,J

A.   Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B.   Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C.   Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D.   Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E.   Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F.   Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G.   Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H.   Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I.   Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J.   Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.

A. Cough B. Recurrent emesis C. Inadequate weight gain D. Irritability

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the parent of a school-age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a 4-month-old infant in the outpatient setting. Exhibits For each assessment finding, click to specify if the finding is consistent with hypertrophic pyloric stenosis or gastroesophageal reflux. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

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A nurse in an outpatient clinic is caring for a school-age child who has cystic fibrosis. Which of the following findings should the nurse monitor as the best indication of the child's nutritional status?