A nurse on a pediatric unit is admitting a 5-year-old child who has a submersion injury and is awake and alert. The parent asks the nurse why the child needs to stay in the facility. Which of the following responses should the nurse make?
"Your child needs mechanical ventilation."
"We need to observe your child for cerebral swelling."
"Your child needs to have an electroencephalogram."
"We need to perform an echocardiogram on your child."
The Correct Answer is B
A. "Your child needs mechanical ventilation." Mechanical ventilation is unnecessary if the child is awake and alert.
B. "We need to observe your child for cerebral swelling." Submersion injuries can lead to complications like cerebral edema or acute respiratory distress syndrome (ARDS), even if the child initially appears stable. Observation is essential to identify and address delayed complications.
C. "Your child needs to have an electroencephalogram." Electroencephalograms (EEGs) are not routine unless seizures or brain activity concerns are present.
D. "We need to perform an echocardiogram on your child." Echocardiograms are not standard for submersion injuries unless cardiac dysfunction is suspected.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Feed infant in a supine position: Contraindicated
- Supine feeding increases the risk of aspiration and exacerbates reflux.
Offer smaller, more frequent feedings: Appropriate
- Smaller, frequent feedings reduce gastric distension and reflux episodes.
Thicken formula feedings with rice cereal: Appropriate
- Thickened feedings can help reduce reflux by increasing the weight of the stomach contents.
Place infant in a side-lying position for sleep: Contraindicated
- The recommended sleep position for infants is supine (on the back) to reduce the risk of sudden infant death syndrome (SIDS).
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