A nurse is caring for an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:
Which of the following actions should the nurse take? (Select all that apply)
Implement contact precautions.
Measure the infant's head circumference.
Weigh the infant
Monitor the infant's intake and output.
Offer the infant small, frequent feeding of thickened liquids.
Evaluate the infant's pain level using the FACES scale.
Plan to administer a plain water enema to the infant.
Correct Answer : C,D
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.
B. Head circumference is routine for well-baby visits and neurological conditions (e.g., hydrocephalus). It is not related to pyloric stenosis assessment.
C. Regular weighing is crucial to assess for weight loss due to vomiting and dehydration. Monitoring weight helps evaluate the severity of the infant's condition and the effectiveness of ongoing treatment.
D. Tracking intake and output is essential for managing hydration status and ensuring the infant is receiving adequate fluids. It helps in assessing the balance between fluid loss due to vomiting and fluid replacement.
E. This intervention is not appropriate for hypertrophic pyloric stenosis. The primary treatment for this condition is surgical intervention, and feeding changes alone will not resolve the underlying issue.
F. The FACES scale is typically used for older children who can self-report pain. For an infant, alternative pain assessment methods would be used, such as observing behavioral cues.
G. An enema is not indicated for hypertrophic pyloric stenosis and may worsen the infant's condition. The focus should be on hydration and surgical preparation rather than enemas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintaining a saline-lock is important but not the highest priority in this context.
B. Checking the child's daily weight is a priority to monitor for fluid retention and changes in fluid status, which are critical in managing acute glomerulonephritis.
C. Educating parents is important but comes after ensuring the child's immediate physical needs are addressed.
D. While a no-salt-added diet may be recommended, monitoring fluid status and weight is more urgent for assessing and managing the condition.
Correct Answer is C
Explanation
A. Loosening restrictive clothing is important for ensuring the child’s comfort and preventing injury, but it is not the immediate priority.
B. Placing a pillow under the child’s head can help prevent head injury during a seizure, but positioning the child is more urgent to prevent aspiration.
C. Positioning the child side-lying is the priority because it helps maintain an open airway and reduces the risk of aspiration of vomit during the seizure. Protecting the airway is the most critical intervention in this scenario.
D. Clearing the area of hazards is important to prevent injury during the seizure, but it is secondary to ensuring the child's airway is protected.
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