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. Contact precautions are used for infections that spread through direct or indirect contact with contaminated surfaces or items, which is not the case for measles.
B. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but measles requires different precautions.
C. Protective environment precautions are used for immunocompromised patients to prevent infections but are not specific to measles.
D. Measles is spread through airborne droplets, so airborne precautions are required to prevent the spread of the virus through the air.
Correct Answer is C
Explanation
A. A stool fat content analysis can indicate malabsorption issues but is not definitive for cystic fibrosis.
B. Pulmonary function tests assess lung function but do not confirm cystic fibrosis.
C. The sweat chloride test is the primary diagnostic test for cystic fibrosis, as it measures the amount of chloride in sweat, which is elevated in this condition.
D. A sputum culture can help identify respiratory infections but does not confirm cystic fibrosis.
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