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 A
Explanation
Choice A: This action is appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it meets their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children develop a sense of competence and achievement by mastering skills and tasks that are valued by society. Encouraging the client to complete school work can help them maintain their academic progress and self-esteem.
Choice B: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need consistency and structure to develop a sense of competence and achievement. Varying the child's schedule each day can cause confusion and stress for them.
Choice C: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need opportunities to master skills and tasks that are valued by society. Providing a daily session with a play therapist can help them cope with their emotions and fears, but it does not help them develop their competence and achievement.
Choice D: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need social support and peer interaction to develop a sense of competence and achievement. Discouraging visits from the client's friends can cause isolation and depression for them.
Correct Answer is B
Explanation
Choice A: This instruction is not correct, as the child should avoid taking a tub bath for the first 3 days after a cardiac catheterization, which is a procedure that involves inserting a thin tube into a blood vessel and advancing it to the heart to diagnose or treat heart problems. Taking a tub bath can increase the risk of infection or bleeding at the insertion site, which is usually in the groin or arm. The child should take a shower instead and keep the insertion site clean and dry.
Choice B: This instruction is correct, as the child may experience some discomfort or soreness at the insertion site after a cardiac catheterization. Giving the child acetaminophen can help relieve the pain and reduce inflammation. The child should avoid taking aspirin or ibuprofen, as they can increase the risk of bleeding.
Choice C: This instruction is not correct, as the child does not need to stay home for 1 week after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume normal activities within 2 to 3 days after the procedure, as long as they avoid strenuous exercise, heavy lifting, or contact sports.
Choice D: This instruction is not correct, as the child does not need to limit their diet to clear liquids for the first 24 hours after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume their regular diet as soon as they feel hungry and drink plenty of fluids to flush out the contrast dye used during the procedure.
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