A nurse is caring for a 6-week-old infant whose guardian reports intermittent vomiting for several days.

Nurses' Notes

Guardian reports infant has been forcefully vomiting after feedings. Guardian states the emesis is so forceful that it often lands 3 to 4 feet away. Infant is very fussy and rooting and sucks vigorously on a pacifier.

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

(Select All that Apply.).

Implement droplet precautions,

Prepare the infant for surgical correction.

Evaluate the infant's pain level using the FLACC scale.

Monitor the infant's intake and output.

Offer the infant small, frequent feedings of thickened liquids

Plan to administer a plain water enema to the infant

Answer and Explanation

Correct Answer : B,C,D

A. Droplet precautions are typically used for infections transmitted through respiratory droplets, such as influenza or COVID-19. Since the symptoms described are more consistent with pyloric stenosis rather than an infectious disease, droplet precautions are not indicated.

B. The infant's symptoms are indicative of possible hypertrophic pyloric stenosis, a condition where the pylorus (the opening from the stomach to the small intestine) becomes narrowed, leading to forceful vomiting and dehydration. Surgical intervention, such as a pyloromyotomy, is often required to correct this condition.

C. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used to assess pain in infants and young children who cannot verbalize their discomfort. Given the infant's fussiness and symptoms, evaluating pain is crucial to managing the infant's discomfort.

D. Monitoring intake and output is important in an infant with vomiting to assess for dehydration and ensure appropriate fluid balance. This is a key aspect of managing any vomiting-related condition and ensuring the infant receives adequate hydration.

E. In the case of hypertrophic pyloric stenosis, thickened liquids are not recommended. The main treatment is surgical, and feeding modifications alone will not address the underlying condition.

F. A plain water enema is not appropriate for this infant’s symptoms. Hypertrophic pyloric stenosis does not require an enema and may actually worsen the infant's condition.

Nursing Test Bank

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Correct Answer is A

Explanation

A. The varicella vaccine, which is a live attenuated vaccine, may be withheld if the child is symptomatic of their illness or has a significantly compromised immune system. This is due to the increased risk of severe reactions or complications in immunocompromised individuals.

B. The vaccination schedule is still applicable to children with HIV, but there may be adjustments based on the child’s immunocompetence and specific health status.

C. The pneumococcal vaccine is recommended for children with HIV and is typically administered according to the standard schedule, not delayed until the first birthday.

D. The HPV vaccine is generally recommended for children with HIV, as they are at increased risk for HPV-related complications. It is not contraindicated.

A. Partial thromboplastin time B. Hemoglobin level C. Platelet count D. Hematocrit level

Correct Answer is A

Explanation

A. Hemophilia is a bleeding disorder that affects the clotting process, and the partial thromboplastin time (PTT) is typically prolonged in individuals with hemophilia, indicating a deficiency in clotting factors.

B. Hemoglobin levels may remain normal unless the client experiences significant bleeding episodes.

C. Platelet count is usually normal in hemophilia, as the disorder affects clotting factors rather than platelet production.

D. Hematocrit levels may also remain normal unless there is significant bleeding, which would lower hematocrit due to blood loss.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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