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 statement is correct, as the mother should notify the doctor if the child's temperature is not controlled with acetaminophen, which is an antipyretic and analgesic medication that can lower fever and relieve pain. A high fever can increase the child's metabolic rate and insulin requirements, which can lead to hyperglycemia or ketoacidosis.
Choice B: This statement is incorrect, as the mother should check the child's blood sugar more frequently than two times every day, especially when the child is sick. An upper respiratory infection can cause inflammation and stress hormones, which can increase the child's blood sugar levels and insulin needs. The mother should monitor the child's blood sugar at least four times a day or more often if indicated by symptoms or ketone testing.
Choice C: This statement is correct, as the mother should encourage the child to drink half a cup of water or sugar-free fluids every 30 minutes, which can prevent dehydration and flush out excess glucose and ketones from the body. Dehydration can worsen hyperglycemia and ketoacidosis, which are serious complications of diabetes.
Choice D: This statement is correct, as the mother should report a change in the child's breathing or any signs of confusion, which can indicate respiratory distress or cerebral edema. Respiratory distress can occur due to hypoxia or acidosis, which can impair oxygen delivery and carbon dioxide elimination. Cerebral edema can occur due to fluid shifts or electrolyte imbalances, which can cause increased intracranial pressure and neurological impairment.
Correct Answer is A
Explanation
Choice A: Encouraging the parents to rock the infant is an appropriate action for a nurse to take, as it can provide comfort, security, and bonding for the infant who is recovering from surgery. Rocking can also soothe the infant's pain and distress and promote sleep and relaxation.
Choice B: Administering blood thinners as needed for pain is not an appropriate action for a nurse to take, as blood thinners are not analgesics and can cause bleeding complications in an infant who is postoperative. Blood thinners are medications that prevent or reduce blood clotting, which can increase the risk of hemorrhage or hematoma. The nurse should administer analgesics, such as acetaminophen or ibuprofen, as prescribed by the provider for pain relief.
Choice C: Positioning the infant on her abdomen is not an appropriate action for a nurse to take, as it can cause pressure or trauma to the surgical site and increase the risk of infection or dehiscence. Positioning the infant on her abdomen can also impair the infant's breathing and oxygenation and increase the risk of sudden infant death syndrome (SIDS). The nurse should position the infant on her back or side with her head elevated and supported.
Choice D: Offering the infant a pacifier is not an appropriate action for a nurse to take, as it can cause suction or friction on the surgical site and increase the risk of infection or dehiscence. Offering the infant a pacifier can also interfere with the infant's feeding and nutrition and cause nipple confusion or preference. The nurse should avoid giving the infant anything in her mouth except for a bottle or breast with a special nipple that does not touch the surgical site.
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