A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals.
Which of the following responses by the nurse is appropriate?
“Bring your infant into the clinic today to be seen.”.
“Burp your child more frequently during feedings.”.
“Give your infant an oral rehydrating solution.”.
“You might want to try switching to a different formula.”.
The Correct Answer is A
Choice A rationale
The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention.
Choice B rationale
While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described.
Choice C rationale
While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution.
Choice D rationale
Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body’s response to inflammation and infection.
Choice B rationale
Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process.
Choice C rationale
A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis.
Choice D rationale
Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.
Correct Answer is B
Explanation
Choice A rationale
Shingles, also known as herpes zoster, is a viral infection that causes a painful rash and is caused by the varicella-zoster virus, the same virus that causes chickenpox.
Choice B rationale
Tinea pedis is a foot infection due to a dermatophyte fungus. It is the most common dermatophyte infection and is particularly prevalent in hot, tropical, urban environments. Interdigital involvement is most commonly seen (this presentation is also known as athlete’s foot, although some people use the term for any kind of tinea pedis).
Choice C rationale
Fever blister, also known as cold sores, are caused by the herpes simplex virus. They are small, fluid-filled blisters that develop on the lips or around the mouth.
Choice D rationale
Pinworms are a type of parasite that lives in the lower intestine of humans. They are tiny, narrow worms. They are white and less than a half-inch long.
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