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. Sitting the child upright and forward while applying pressure to the sides of the nose is the correct approach to managing a nosebleed. This position prevents blood from flowing down the throat and helps stop the bleeding by applying direct pressure.
B. Turning the child's head to the side and pressing on the nasal ridge is incorrect because it does not effectively control the bleeding and may cause blood to flow into the throat.
C. Lying the child in bed and pressing on the forehead is not effective in controlling a nosebleed.
D. Lying flat and applying pressure to the cheeks does not address the source of the bleeding and may worsen the situation.
Correct Answer is D
Explanation
A. Constipation is not a typical manifestation of a sickle cell crisis.
B. High fever may occur if an infection is present, but it is not a hallmark symptom of a sickle cell crisis.
C. Bradycardia is not expected during a sickle cell crisis; if anything, tachycardia may be seen due to pain or anemia.
D. Pain is the most common and significant symptom of a sickle cell crisis, caused by the obstruction of blood flow by sickled red blood cells, leading to ischemia and severe pain. This requires immediate attention and pain management.
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