A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?
"Bring your baby into the clinic today."
"Give your infant an oral rehydration solution."
"Burp your baby more frequently during feedings."
"Try switching to a different formula."
The Correct Answer is A
Choice A: This response is appropriate, as it indicates urgency and concern for the infant's condition. Projectile vomiting immediately after eating can be a sign of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Pyloric stenosis can prevent food from passing through and cause dehydration, electrolyte imbalance, or weight loss. The infant needs to be evaluated by a provider as soon as possible and may need surgery to correct the problem.
Choice B: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Oral rehydration solution can help replace fluids and electrolytes lost through vomiting, but it does not treat pyloric stenosis or prevent further vomiting. Oral rehydration solution may also be vomited out by the infant if given too soon or too much.
Choice C: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Burping the baby more frequently during feedings can help release air bubbles and prevent gas or colic, but it does not treat pyloric stenosis or prevent further vomiting. Burping may also trigger vomiting by increasing pressure on the stomach.
Choice D: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Switching to a different formula can help if the infant has an allergy or intolerance to certain ingredients in their current formula, but it does not treat pyloric stenosis or prevent further vomiting. Switching formulas may also cause diarrhea or constipation by changing the infant's bowel flora.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Cranberry juice is not a suitable fluid item to offer the child at this time, as it is acidic and can irritate the throat and cause pain or bleeding. Cranberry juice can also stain the surgical site and make it difficult to assess for signs of hemorrhage.
Choice B: Crushed ice is a suitable fluid item to offer the child at this time, as it is cold and can soothe the throat and
reduce swelling or inflammation. Crushed ice can also hydrate the child and prevent dehydration.
Choice C: Orange juice is not a suitable fluid item to offer the child at this time, as it is acidic and can irritate the throat and cause pain or bleeding. Orange juice can also interfere with the clotting process and increase the risk of hemorrhage.
Choice D: A strawberry milkshake is not a suitable fluid item to offer the child at this time, as it contains dairy products and can increase mucus production and cause coughing or gagging. A strawberry milkshake can also stain the surgical site and make it difficult to assess for signs of hemorrhage.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because having them share a room with a child with active mumps may expose them to infection and worsen their condition. A child who is immunosuppressed due to leukemia or chemotherapeutic agents has a weakened immune system and is more susceptible to infections from bacteria, viruses, fungi, or parasites. Therefore, they should be placed in a private room or cohorted with another immunosuppressed child.
Choice B reason: This choice is incorrect because restricting oral fluids may cause dehydration and electrolyte imbalance in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may have increased fluid losses from vomiting, diarrhea, fever, or sweating. Therefore, they should be encouraged to drink adequate fluids to maintain hydration and electrolyte balance.
Choice C reason: This choice is incorrect because strict isolation may cause psychological distress and social isolation in the child who is immunosuppressed due to leukemia or chemotherapeutic agents. A child who is immunosuppressed due to leukemia or chemotherapeutic agents may benefit from protective isolation, which involves using standard precautions and additional measures such as wearing gloves, gowns, masks, or eye protection when in contact with the child or their body fluids. However, strict isolation, which involves limiting visitors and activities, may harm the child's emotional and developmental well-being.
Choice D reason: This choice is correct because using good handwashing is essential nursing care for a child who is immunosuppressed due to leukemia or chemotherapeutic agents. Handwashing is the most effective way to prevent the transmission of microorganisms that can cause infections. The nurse should wash their hands before and after touching the child or their belongings, and teach the child and their family members to do the same. The nurse should also use alcohol-based hand rubs when water and soap are not available.
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