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 A
Explanation
A. Agitation can be a sign of hypoxemia, as the body responds to low oxygen levels with restlessness and anxiety.
B. Nausea is less directly related to hypoxemia and more often associated with other conditions.
C. Hypotension is not a typical primary manifestation of hypoxemia; it is more associated with severe or advanced stages of illness.
D. Dysphagia (difficulty swallowing) is not a common symptom of hypoxemia during an asthma attack.
Correct Answer is B
Explanation
A. Isosorbide dinitrate is a nitrate that helps to dilate blood vessels and reduce the workload on the heart. It is generally safe for clients with asthma.
B. Carvedilol is a beta-blocker used to manage heart failure, but it can also cause bronchoconstriction, which is dangerous for clients with asthma. Beta-blockers can exacerbate asthma symptoms, so clarification is needed before administration.
C. Fluticasone is a corticosteroid commonly used to manage asthma and other respiratory conditions; it is not contraindicated for this client.
D. Captopril is an ACE inhibitor used to treat heart failure and does not pose a risk for clients with asthma.
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