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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This choice is correct because examining the child's tympanic membrane at the end of the physical examination is the best strategy to avoid upsetting or frightening the child. The tympanic membrane is the thin membrane that separates the outer ear from the middle ear, and it can be examined by using an otoscope, which is a device that has a light and a magnifying lens. Examining the tympanic membrane may be uncomfortable or painful for the child, especially if they have an ear infection or inﬂammation. Therefore, performing this procedure at the end of the examination can help to minimize the child's distress and resistance.

Choice B reason: This choice is incorrect because examining the child's tympanic membrane before auscultating the chest and abdomen is not a good strategy to avoid upsetting or frightening the child. Auscultating the chest and abdomen is a procedure that involves listening to the sounds of the heart, lungs, and bowel by using a stethoscope, which is a device that has a chest piece and earpieces. Auscultating the chest and abdomen may be soothing or relaxing for the child, as it does not cause any discomfort or pain. Therefore, performing this procedure before examining the tympanic membrane can help to calm and distract the child.

Choice C reason: This choice is incorrect because examining the child's tympanic membrane at the beginning of the physical examination is not a good strategy to avoid upsetting or frightening the child. Examining the tympanic membrane at the beginning of the examination may cause anxiety or fear in the child, which can affect their cooperation and trust for the rest of the examination. Therefore, performing this procedure at the beginning of the examination can increase the child's distress and resistance.

Choice D reason: This choice is incorrect because examining the child's tympanic membrane before examining the
head and neck is not a good strategy to avoid upsetting or frightening the child. Examining the head and neck is a procedure that involves inspecting and palpating the scalp, hair, face, eyes, ears, nose, mouth, throat, lymph nodes, and thyroid gland. Examining the head and neck may be easy or pleasant for the child, as it does not cause any discomfort or pain. Therefore, performing this procedure before examining the tympanic membrane can help to establish rapport and confidence with the child.

A. Restrain the child's arms. B. Use a padded tongue blade. C. Attempt to stop the seizure. D. Position the child laterally.

Correct Answer is D

Explanation

Choice A: Restraining the child's arms is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can cause injury to the child or the nurse. Restraining the child's arms can also increase the child's anxiety and agitation, which can worsen the seizure.

Choice B: Using a padded tongue blade is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can cause injury to the child's mouth, teeth, or tongue. Using a padded tongue blade can also increase the risk of choking or aspiration, which can compromise the child's airway.

Choice C: Attempting to stop the seizure is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can be ineﬀective or harmful. Attempting to stop the seizure can also interfere with the natural course of the seizure, which may be necessary for the brain to recover.

Choice D: Positioning the child laterally is an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can help maintain the child's airway and prevent aspiration. Positioning the child laterally means placing the child on their side with their head tilted slightly forward and their mouth open.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? (The child will likely view this as invasive and traumatic)

Correct Answer is A

Explanation

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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