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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Measure the infant's head circumference.

Weigh the infant.

Monitor intake and output.

Offer small frequent feedings of thickened liquids.

Evaluate serum electrolyte levels.

Plan to administer a plain water enema.

Implement contact precautions.

Answer and Explanation

Correct Answer : B,C,E

A. Measure the infant's head circumference. Measuring head circumference is a standard part of routine well-child exams and growth monitoring, but it is not directly relevant to the current diagnosis of hypertrophic pyloric stenosis. The immediate clinical focus is on the gastrointestinal symptoms and associated dehydration.
B. Weigh the infant. Weighing the infant is crucial for monitoring weight loss and assessing hydration status. Infants with hypertrophic pyloric stenosis are at risk of dehydration and malnutrition due to frequent, forceful vomiting. Regular weight checks help in evaluating the effectiveness of treatment and the nutritional status of the infant.
C. Monitor intake and output. Monitoring intake and output is vital in this scenario to assess the infant's hydration status and kidney function. Given the forceful vomiting, there's a high risk of dehydration, as indicated by the dry mucous membranes, depressed fontanel, and reduced urine output. Accurate measurement helps guide fluid replacement therapy.
D. Offer small frequent feedings of thickened liquids. Offering feedings, even of thickened liquids, is inappropriate in this situation because the infant requires surgical intervention for pyloric stenosis. Continued feeding may exacerbate vomiting and dehydration. Instead, the infant should be kept NPO (nothing by mouth) to prepare for surgery and prevent further complications.
E. Evaluate serum electrolyte levels: Infants with hypertrophic pyloric stenosis often develop electrolyte imbalances such as hypokalemia, hypochloremia, and metabolic alkalosis due to prolonged vomiting. Evaluating serum electrolytes is essential to identify and correct these imbalances, which are critical to stabilizing the infant before surgical intervention.
F. Plan to administer a plain water enema. A plain water enema is not indicated and is inappropriate for treating hypertrophic pyloric stenosis. The issue is not related to bowel movements or lower gastrointestinal obstruction, but rather to the pyloric sphincter in the stomach, which requires surgical correction.
G. Implement contact precautions. Contact precautions are typically used to prevent the spread of infectious diseases. Hypertrophic pyloric stenosis is not an infectious condition but a structural anomaly. Thus, there is no need for contact precautions in this context.

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Correct Answer is D

Explanation

A. Regular diet, no added salt: A regular diet with no added salt does not adequately address the sodium restriction needed to manage edema in acute glomerulonephritis.
B. Low-carbohydrate, low-protein diet: Restricting carbohydrates and proteins is not typically necessary in acute glomerulonephritis unless there are specific complications.
C. Low-protein, low-potassium diet: While protein restriction may be necessary in chronic kidney disease, it is not typically the primary focus in managing acute glomerulonephritis.
D. Low-sodium, fluid-restricted: A low-sodium diet helps to reduce fluid retention and manage edema in acute glomerulonephritis. Fluid restriction may also be necessary to manage fluid balance.

A. Diarrhea B. Swollen joints C. Abdominal mass D. Jaundice

Correct Answer is C

Explanation

A. Diarrhea: Diarrhea is not a typical finding associated with Wilms' tumor.
B. Swollen joints: Swollen joints are not associated with Wilms' tumor and would suggest a different condition.
C. Abdominal mass: Wilms' tumor typically presents with an asymptomatic abdominal mass that may be firm, non-tender, and palpable.
D. Jaundice: Jaundice is not typically associated with Wilms' tumor and would suggest liver dysfunction or another underlying cause.

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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission: Exhibits Which of the following actions should the nurse take? Select all that apply.

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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:

Exhibits

Which of the following actions should the nurse take? Select all that apply.