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
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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While placing a pillow under the child’s head might seem like a good idea, it’s actually not recommended during a seizure. The child’s movements could be unpredictable, and a pillow could potentially cause suffocation.
Choice B rationale
Removing the child’s eyeglasses is a good idea, but it’s not the first thing you should do. The child’s safety is the top priority, and eyeglasses can be removed once the child is safe.
Choice C rationale
Timing the seizure is important for medical professionals to know, but it’s not the first action to take. The child’s immediate safety is the priority.
Choice D rationale
Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
Correct Answer is B
Explanation
The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.
Rationale for each choice:
- Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
- Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
- Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
- Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.
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