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
Sterile water
Oral electrolyte solution
Half-strength orange juice
The Correct Answer is C
A. Half-strength infant formula: Infant formula, even if diluted, may not be appropriate immediately after a repair of intussusception. It may be too heavy for the infant's digestive system, potentially leading to complications. Clear fluids are usually preferred initially.
B. Sterile water: Sterile water is not typically recommended for oral intake in infants after a repair of intussusception. It lacks essential electrolytes needed to maintain proper hydration and electrolyte balance.
C. Oral electrolyte solution: Oral electrolyte solutions, such as Pedialyte, are often recommended for infants after a repair of intussusception. These solutions contain balanced electrolytes and fluids, which help prevent dehydration and restore electrolyte balance.
D. Half-strength orange juice: Orange juice, even if diluted, is not typically recommended immediately after a repair of intussusception. It may be too acidic and may cause gastrointestinal discomfort or irritation in the infant. Clear fluids are preferred initially to allow the gastrointestinal tract to rest and recover.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limit time for the client to perform activities. This intervention is not appropriate for a client with Alzheimer's disease. Limiting time for activities may increase agitation and frustration in individuals with cognitive impairments. Instead, it's important to allow adequate time for tasks and provide support as needed.
B. Talk the client through tasks one step at a time. This intervention is appropriate for a client with Alzheimer's disease. Breaking tasks into manageable steps and providing clear, simple instructions can help the client better understand and complete activities. This approach reduces confusion and frustration and promotes independence to the extent possible.
C. Provide an activity schedule that changes from day to day. Consistency is key in caring for individuals with Alzheimer's disease. A changing activity schedule may lead to increased confusion and disorientation. It's important to establish a routine and maintain consistency in daily activities and schedules to provide a sense of security and familiarity for the client.
D. Rotate assignment of daily caregivers. Consistency in caregiver assignments is essential for individuals with Alzheimer's disease. Changing caregivers frequently can disrupt the client's sense of security and increase confusion and anxiety. Continuity of care helps build trust and rapport between the client and caregivers, which is beneficial for the client's overall well-being.
Correct Answer is A
Explanation
A. Projectile vomiting: Pyloric stenosis is a condition characterized by the narrowing of the pylorus, the opening between the stomach and the small intestine. This narrowing leads to obstruction of the gastric outlet, causing the stomach to become distended with food. When the infant feeds, the stomach fills up, but the food cannot pass through the narrowed pylorus efficiently. As a result, the infant forcefully expels the contents of the stomach in a characteristic manner known as projectile vomiting. Projectile vomiting is forceful, often occurring shortly after feeding, and the vomited material is usually not bile-stained.
B. Ridged abdomen: While abdominal distension can occur due to the buildup of gastric contents in pyloric stenosis, the term "ridged abdomen" is not typically associated with this condition. Instead, clinicians may palpate an olive-shaped mass in the right upper quadrant of the abdomen, which represents the hypertrophied pylorus. The ridged appearance may be more indicative of conditions such as peritonitis or muscular rigidity, rather than pyloric stenosis.
C. Distended neck veins: Distended neck veins are not typically associated with pyloric stenosis. This symptom is more commonly observed in conditions affecting the cardiovascular system, such as congestive heart failure. In pyloric stenosis, the primary manifestations are related to gastrointestinal obstruction, particularly projectile vomiting, rather than signs of circulatory compromise.
D. Red currant jelly stools: Red currant jelly stools are a characteristic finding in intussusception, a condition where one portion of the intestine telescopes into another, causing obstruction and compromise of the blood supply. This leads to the passage of stools containing blood and mucus, resembling red currant jelly in appearance. Pyloric stenosis primarily affects gastric emptying and does not typically result in bloody stools. Instead, the hallmark symptom is projectile vomiting due to gastric outlet obstruction.
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