A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit.

The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks.

Parents report the vomiting is now forceful and projectile (“like a volcano erupting”) immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry.

The infant has been receiving a cow’s milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks.

The last weight in the pediatrician’s office is 3.54kg (8 lb). No other significant medical or surgical history.

What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client’s progress?

Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits

Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency

Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency

Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions

Answer and Explanation

The Correct Answer is B

Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years19.
Choice B rationale
The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease19.
Choice C rationale
The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver19.
Choice D rationale
The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin19.

A. Yogurt B. Gelatin C. Strained soup D. Pureed fruit

Correct Answer is B

Explanation

Choice B rationale
Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature.
Choice A rationale
Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature.
Choice C rationale
Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed.
Choice D rationale
Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?

Correct Answer is D

Explanation

A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?

Correct Answer is B

Explanation

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care actions should the nurse recommend? (Select all that apply)

A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parent about illness management. Which of the following instructions should the nurse include?

A nurse is attending a continuing education course about communicable diseases. The nurse should identify that varicella has which of the following incubation periods?

Which statement from a parent of a 1-month-old infant undergoing initial surgery for Hirschsprung’s disease indicates understanding of the surgery’s goal?

A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?

A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non-corrosive substance that has no recommended antidote. The nurse should recommend performing gastric lavage with which of the following substances?

A nurse is caring for a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is: