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: This action is not appropriate, as it may cause more harm than good to separate the child from the parents without sufficient evidence or reason. Separating the child from the parents can cause fear, anxiety, or resentment in both parties and may interfere with establishing rapport and trust. The nurse should only separate the child from the parents if there is an immediate threat or danger to the child's safety.
Choice B: This action is premature, as it may violate confidentiality and ethical principles to report suspected abuse to the authorities without sufficient evidence or reason. Reporting suspected abuse to the authorities can have serious legal and social consequences for both parties and may escalate or worsen the situation. The nurse should only report suspected abuse to the authorities if there is clear evidence or indication of abuse or if mandated by law.
Choice C: This action is irrelevant, as it may not address the issue or help resolve it to ask a psychiatrist to talk with the parents without sufficient evidence or reason. Asking a psychiatrist to talk with the parents can imply that they have mental health problems or that they are guilty of abuse, which can cause stigma, anger, or denial. The nurse should only ask a psychiatrist to talk with the parents if there is evidence or indication of mental health problems or if requested by them.
Choice D: This action is appropriate, as it can help determine whether there is any evidence or reason to suspect abuse or not. Obtaining a detailed history can provide information about how, when, where, and why the bruises occurred and whether they are consistent with accidental or intentional injury. The nurse should obtain a detailed history from both parties separately and in a nonjudgmental and supportive manner.
Correct Answer is A
Explanation
Choice A reason: This is a therapeutic response that acknowledges the parent's feelings and provides reassurance that the behavior is normal and temporary. The other responses are either dismissive, judgmental, or self-disclosing, which are not helpful for the parent.
Choice B reason: This is a judgmental response that implies that the parent is overreacting or has unrealistic expectations for their child.
Choice C reason: This is a dismissive response that minimizes the parent's concern and does not offer any support
or information.
Choice D reason: This is a self-disclosing response that shifts the focus from the parent to the nurse and does not
address the issue at hand.
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