A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?
Half-strength infant formula
Half-strength orange juice
Sterile water
Oral electrolyte solution
The Correct Answer is D
Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.
Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.
Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.
Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Absent bowel sounds are not a finding that indicates perforation of the appendix. Absent bowel sounds could be a sign of ileus, obstruction, or peritonitis, but they are not specific to appendicitis.
Choice B reason: Low-grade fever is not a finding that indicates perforation of the appendix. Low-grade fever could be a sign of infection, inflammation, or dehydration, but it is not specific to appendicitis.
Choice C reason: Sudden decrease in abdominal pain is a finding that indicates perforation of the appendix. Sudden decrease in abdominal pain means that the pressure inside the appendix has been released, causing the appendix to rupture and spill its contents into the peritoneal cavity. This can lead to severe complications such as sepsis, abscess, or shock.
Choice D reason: Flaccid abdomen is not a finding that indicates perforation of the appendix. Flaccid abdomen could be a sign of muscle relaxation, sedation, or paralysis, but it is not specific to appendicitis.
Correct Answer is C
Explanation
Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.
Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.
Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.
Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.
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