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","B","C"]
Explanation
A. Removing objects from the bed is necessary to prevent injury during the seizure.
B. Placing the client in a side-lying position helps to maintain an open airway and reduces the risk of aspiration.
C. Assessing airway patency is crucial to ensure the client can breathe adequately during and after the seizure.
D. Placing a tongue depressor or any object in the client's mouth is contraindicated, as it can cause injury or obstruct the airway.
E. Restraining the client is also contraindicated because it can cause harm or increase agitation during a seizure.
Correct Answer is A
Explanation
A. Toddlers are beginning to cooperate in simple chores and tasks, which aligns with their developmental stage.
B. Toddlers often struggle with separation anxiety and do not separate easily from their caregivers.
C. Understanding the difference between right and wrong is a skill that develops later, typically around age 4 or older.
D. Printing letters and numbers is beyond the developmental capabilities of a toddler and is expected later in early childhood.
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