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 B
Explanation
Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
Correct Answer is C
Explanation
The correct answer is Choice C.
Step 1: Convert the child’s weight from lbs to kg.
Since 1 lb is approximately 0.45 kg, a child who weighs 6 lbs weighs approximately 2.72 kg (6 lbs × 0.45 =2.72 kg). Step 2: Calculate the total daily dose of Ampicillin. The total daily dose is 50 mg/kg/day, so for a child who weighs 2.72 kg, the total daily dose would be approximately 136 mg (50 mg/kg/day × 2.72 kg = 136 mg/day). Step 3: Since the total daily dose is divided into q hr doses (4 doses per day), each dose would be approximately 34 mg (136 mg/day ÷ 4 doses/day = 34 mg/dose). So, the child will receive approximately 34 mg of Ampicillin with each dose.
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