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 D
Explanation
A. Administering intravenous antibiotics is crucial for treating bacterial meningitis, but isolation is the priority to prevent the spread of infection.
B. Preparing for a lumbar puncture is important for diagnosis, but ensuring the child is isolated to prevent transmission is the immediate concern.
C. Obtaining blood cultures is important for identifying the causative organism but does not take precedence over isolation.
D. Placing the child in isolation is the priority to prevent the spread of bacterial meningitis, which is highly contagious.
Correct Answer is C
Explanation
A. This site is used most often to obtain a pulse in infants during CPR or blood pressure measurement, but it does not provide the most accurate heart rate assessment.
B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.
C. The apical pulse (measured with a stethoscope at the 4th intercostal space, left midclavicular line) is the most accurate site for infants and children under 2 years old. It directly reflects the heart’s activity and is less affected by peripheral perfusion.
D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.
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