A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)

Wheezing

Rigid abdomen

Pallor

Weight loss

Vomiting

Answer and Explanation

Correct Answer : A,D,E

A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract.

B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants.

C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER.

D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively.

E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.

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Correct Answer is A

Explanation

A. "My belly doesn't hurt anymore."

- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.

B. "I am hungry and thirsty."

- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.

C. "I'm tired and want to take a nap."

- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.

D. "I am scared and I want to go home."

- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.

A. Maintain a saline-lock. B. Check the child's weight daily. C. Place the child on a no-salt-added diet. D. Educate the parents about potential complications.

Correct Answer is B

Explanation

A. Maintain a saline-lock:

While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring fluid balance and electrolyte levels may be necessary, but the immediate priority is to educate the parents about potential complications.

B. Check the child's weight daily:

Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.

C. Place the child on a no-salt-added diet:

Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage.

D. Educate the parents about potential complications:

Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.

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A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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