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.

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Correct Answer is B

Explanation

Choice A rationale
Hypotension, or low blood pressure, is not typically associated with nephrotic syndrome. In fact, some patients with nephrotic syndrome may experience high blood pressure.
Choice B rationale
Generalized edema, or swelling, is a common characteristic of nephrotic syndrome. It occurs due to the loss of proteins in the urine, which leads to a decrease in the amount of protein in the blood. This decrease in blood protein levels causes fluid to move from the blood vessels into the tissues, leading to swelling.
Choice C rationale
Increased urinary output is not typically associated with nephrotic syndrome. In fact, some patients may experience decreased urine output.
Choice D rationale
Bright red blood in the urine is not a typical symptom of nephrotic syndrome. Hematuria, or blood in the urine, when present in nephrotic syndrome, is usually microscopic and not visible to the naked eye.

A. Turn the client to a lateral position. B. Administer an anticonvulsant medication. C. Apply oxygen by nasal cannula. D. Check the client’s oxygen saturation.

Correct Answer is A

Explanation

Choice A rationale
The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury.
Choice B rationale
Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice C rationale
Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice D rationale
Checking the client’s oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.

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Naxlex Comprehensive Predictor Exams

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:

Correct Answer is B

Explanation

Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?

Correct Answer is A

Explanation

A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:

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 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?

Your child will need to increase his calcium intake to 3,000 milligrams daily. A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a child who has tinea pedis. The child’s parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?

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A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?