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 : B,C,D
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.
B. This is important for monitoring for signs of increased intracranial pressure due to potential dehydration and electrolyte imbalances. In cases of severe vomiting and dehydration, monitoring head circumference can help assess the impact on brain hydration status.
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 C
Explanation
A. Enlarged mandibular growth is not characteristic of sickle-cell anemia.
B. Depigmented areas on the abdomen are not associated with sickle-cell anemia.
C. Slightly yellow sclera (jaundice) is consistent with sickle-cell anemia due to the breakdown of red blood cells, which can lead to an increased level of bilirubin.
D. Increased growth of long bones is not typically associated with sickle-cell anemia; instead, there may be pain and deformities related to sickle cell crises.
Correct Answer is C
Explanation
A. Erikson's stage of initiative versus guilt typically occurs during the preschool years (3-6 years), not the toddler stage.
B. Imaginary playmates are more characteristic of the preschool years rather than the toddler stage.
C. Toddlers are in Erikson's stage of autonomy versus shame and doubt, characterized by negative behaviors as they assert independence and develop autonomy.
D. Demonstrations of sexual curiosity become more pronounced during the preschool years and are less typical in the toddler stage.
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