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. Testing urine for ketones is important during illness as it can indicate the presence of ketoacidosis, a potentially life-threatening complication in children with type 1 diabetes.
B. Withholding insulin during illness is dangerous, as the body may require more insulin due to increased stress and glucose production.
C. While notifying the provider for high blood glucose levels is essential, it is not the first action to take. Monitoring for ketones is crucial during illness.
D. Limiting fluid intake is not advised during illness, as adequate hydration is important to prevent dehydration and assist in glucose regulation.
Correct Answer is D
Explanation
A. Switching formula is not the first intervention, as projectile vomiting in an infant can indicate a more serious condition such as pyloric stenosis, which requires medical evaluation.
B. Oral rehydration solution may be needed if the infant is dehydrated, but the cause of vomiting must be assessed first.
C. While burping can reduce gas and discomfort, it is unlikely to resolve projectile vomiting, which may be due to a more serious underlying condition.
D. Bringing the baby to the clinic is the most appropriate action, as projectile vomiting can be a sign of pyloric stenosis or another serious condition that requires prompt medical attention.
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