The nurse admits to the clinic a 7-month-old infant whose parents report that the baby has not had a bowel movement in 4 days.
What is the nurse’s best action?
Administer a glycerin suppository as prescribed.
Administer magnesium hydroxide as prescribed.
Encourage watchful waiting for 24 hours.
Encourage feeding supplementation with free water.
The Correct Answer is A
Glycerin suppositories are safe and effective for infants with constipation. They work by lubricating and softening the stool, and stimulating the rectal muscles to contract.
Choice B is wrong because magnesium hydroxide is not recommended for infants under 6 months of age, and may cause diarrhea, electrolyte imbalance, or magnesium toxicity.
Choice C is wrong because watchful waiting for 24 hours may not be enough to relieve the infant’s discomfort and may lead to further complications such as fecal impaction or dehydration.
Choice D is wrong because feeding supplementation with free water may not be sufficient to treat constipation, and may dilute the infant’s intake of nutrients and electrolytes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse would assess these factors to determine the need for therapy. Some possible explanations for the other choices are:
Choice A. Number of times client’s family reports the client is nauseated.
This is not a reliable indicator of the severity or cause of nausea and vomiting.
The nurse should assess the client directly and not rely on the family’s reports.
Choice B. How well the client is eating.
This is not a specific or objective measure of nausea and vomiting.
The client may have other reasons for not eating well, such as loss of appetite, taste changes, or pain.
The nurse should also monitor the client’s weight, hydration status, and electrolyte levels.
Choice D. Client’s nutritional status and fluid balance.
These are important aspects of the client’s overall health, but they are not directly related to nausea and vomiting.
The nurse should assess these factors as part of the comprehensive care plan, but they are not sufficient to determine the need for therapy.
Correct Answer is B
Explanation
Choice A is wrong because tetraiodothyronine is another name for thyroxine (T), which is a hormone produced by the thyroid gland, not the anterior pituitary gland.14
Choice C is wrong because triiodothyronine (T) is also a hormone produced by the thyroid gland, not the anterior pituitary gland.14
Normal ranges for TSH are 0.4 to 4.0 mIU/L, for T are 100 to 200 ng/dL, and for T are 4.5 to 11.2 mcg/dL.1
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