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.

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Correct Answer is D

Explanation

A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.

B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.

C. Intravenous immunoglobulins are not indicated based on the current lab values.

D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.

A. "We can anticipate needing intravenous fluids to correct the dehydration." B. "I will continue to give oral rehydration in small amounts." C. "Chicken broth will replace the needed electrolytes lost." D. "If my child's soft spot becomes depressed, I will notify the healthcare provider immediately."

Correct Answer is B

Explanation

A. Intravenous fluids are generally not required if the child is alert and active with mild dehydration; oral rehydration is usually sufficient.

B. Oral rehydration solutions are appropriate for treating mild dehydration and should be given in small amounts frequently.

C. Chicken broth is not ideal for replacing electrolytes because it is low in electrolytes and high in sodium. Oral rehydration solutions are preferred.

D. A depressed soft spot (fontanel) is a sign of severe dehydration in infants. For a 4-year-old, signs of dehydration would include changes in urine output, thirst, or dry mucous membranes rather than a depressed fontanel.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A clinic nurse is caring for a 4-year-old client with acute diarrhea and mild dehydration who is afebrile, active, and alert. The nurse is providing instructions to the parent. Which statement by the parent indicates understanding?

Correct Answer is B

Explanation

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