A nurse is assisting with collecting data from a 10-month-old in the emergency department.

Medical History: Guardians brought the infant to the emergency room after witnessing the infant’s arms and legs shaking.

The infant did not respond to the guardians’ voices during that time.

The episode lasted approximately 5 min and the infant was sleeping soundly afterwards.

On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation.

The infant has no prior medical or surgical history.

Born full-term at 40 weeks to a birth mother who had regular prenatal visits.

Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A rationale
The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years19.
Choice B rationale
The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease19.
Choice C rationale
The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver19.
Choice D rationale
The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin19.

Choice A rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss.
Choice C rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.