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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. Hypertension: Hypertension is not typically associated with nephrotic syndrome unless there are underlying kidney complications.
B. Polyuria: Polyuria (increased urine output) is not typically seen in nephrotic syndrome, which is characterized by proteinuria and edema.
C. Orange-tinged urine: Orange-tinged urine suggests the presence of blood or bilirubin, which is not typically associated with nephrotic syndrome.
D. Periorbital edema: Periorbital edema (swelling around the eyes) is a common manifestation of nephrotic syndrome due to fluid retention.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.

Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.

Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.

Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

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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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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting in the care of a toddler. Exhibits A nurse is assisting in the care of a client. Complete the following sentence by using the list of options. The nurse should first address the child's dropdown followed by the child's dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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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.