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 D
Explanation
Choice A reason: wrong because applying cool compresses for 20 minutes every hour is not typically recommended.While cool compresses can help reduce joint swelling and pain, they are usually recommended to be applied for short periods and not as frequently as every hour
Choice B reason: wrong because while rest is important, there is no specific recommendation for a 45-minute nap daily.Adequate rest should be balanced with physical activity, which is essential for maintaining joint function and muscle strength
Choice C reason: wrong because allowing the child to stay at home on days when her joints are painful may lead to prolonged inactivity, which can worsen joint stiffness and reduce muscle strength.It’s important to encourage regular movement and activity as tolerated
Choice D reason: This is correct because prednisone is a corticosteroid used to reduce inflammation in conditions like juvenile idiopathic arthritis, and an alternate-day schedule can be effective in managing symptoms while minimizing side effects
Correct Answer is A
Explanation
Choice A: A WBC count of 17,000/mm³ is an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates leukocytosis, which is an increase in white blood cells. Leukocytosis can occur in a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the airways and lungs and causes respiratory infections and inflammation. A normal WBC count for children is 5,000 to 10,000/mm³.
Choice B: A neutrophil count of 3,000/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal neutrophil levels. Neutrophils are a type of white blood cell that fight bacterial infections. A normal neutrophil count for children is 1,500 to 8,000/mm³.
Choice C: A lymphocyte count of 3,000/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal lymphocyte levels. Lymphocytes are a type of white blood cell that fight viral infections. A normal lymphocyte count for children is 1,500 to 4,000/mm³.
Choice D: An RBC count of 4.2 million/mm³ is not an abnormal result that the nurse should anticipate when reviewing this client's laboratory values, as it indicates normal red blood cell levels. Red blood cells carry oxygen and carbon dioxide throughout the body. A normal RBC count for children is 4 to 5.5 million/mm³.
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