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: This test will not indicate if the child has rheumatic fever, as rheumatic fever is a complication of an untreated or inadequately treated streptococcal infection that affects the heart, joints, skin, and brain. Rheumatic fever is diagnosed based on clinical criteria, such as carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules.
Choice B: This test will confirm if the child had a recent streptococcal infection, as antistreptolysin O (ASO) is an antibody that the body produces in response to streptococcal bacteria. A high ASO titer indicates that the child was exposed to streptococcal bacteria within the past few weeks. A streptococcal infection can cause pharyngitis, tonsillitis, scarlet fever, or impetigo.
Choice C: This test will not indicate if the child has a therapeutic blood level of an aminoglycoside, as an aminoglycoside is a type of antibiotic that is used to treat serious bacterial infections. A therapeutic blood level of an aminoglycoside means that the drug is effective and safe in the body. A therapeutic blood level of an aminoglycoside is measured by a peak and trough level.
Choice D: This test will not confirm if the child has immunity to streptococcal bacteria, as immunity to streptococcal bacteria means that the body can resist or fight the infection. Immunity to streptococcal bacteria can be acquired by natural exposure or vaccination. Immunity to streptococcal bacteria is measured by an antibody titer or a skin test.
Correct Answer is B
Explanation
Choice A: A heart rate of 72/min is within the normal range for an adolescent, which is 60 to 100 beats per minute. A heart rate of 72/min does not indicate any signs of shock, hemorrhage, or cardiac injury. Therefore, this finding is not the nurse's priority.
Choice B: A blood pressure of 84/52 mm Hg is below the normal range for an adolescent, which is 110 to 120/70 to 80 mm Hg. A blood pressure of 84/52 mm Hg indicates hypotension, which can be a sign of shock, hemorrhage, or internal organ damage. Hypotension can lead to decreased tissue perfusion, organ failure, or death. Therefore, this finding is the nurse's priority and requires immediate intervention.
Choice C: An abdominal pain rated 4 on a scale of 0 to 10 is a moderate level of pain that can indicate inflammation, injury, or infection in the abdomen. However, pain is a subjective symptom that may vary depending on the individual and the severity of the condition. Pain can also be managed with analgesics or other measures. Therefore, this finding is not the nurse's priority.
Choice D: A respiratory rate of 20/min is within the normal range for an adolescent, which is 12 to 20 breaths per minute. A respiratory rate of 20/min does not indicate any signs of respiratory distress, hypoxia, or pulmonary injury. Therefore, this finding is not the nurse's priority.
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