The nurse has reviewed the Nurses' Notes 1 month later.
Exhibit 1. Nurses' Notes.
Today, 1000: Exhibit 2. Infant here at the provider's office for a scheduled visit.
The infant is in their parent's arms, grimacing.
S1 and S2 auscultated, no murmur noted.
Respirations are symmetric and unlabored with abdominal movement.
Abdomen is soft and flat, bowel sounds present.
Current weight is 4.1 kg (9 lb) The parent states they have exclusively breast- and bottle-fed breastmilk to the infant since birth.
The parent states the infant sometimes chokes with bottle feedings.
The parent noticed that the infant recently started "spitting up" during the night and after feeds, and cries excessively.
They state the infant has been vomiting more forcefully and has become disinterested in feeding.
Today, 1010: Exhibit 3. Provider assessed infant and discussed gastroesophageal reflux with parent.
Education provided.
1 month later: Infant here for follow-up visit.
Infant is calm and alert in parent's arms.
Parent states infant is sleeping through the night.
What notable improvement or change has been observed in the infant's condition during the one-month follow-up visit?
Sleeping pattern.
Irritability.
Weight.
Regurgitation.
Heart rate.
The Correct Answer is B
Choice A rationale:
The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.
Choice B rationale:
Irritability is mentioned in the initial notes, indicating the infant's discomfort. However, in the follow-up visit, there is no mention of irritability, suggesting an improvement in this symptom. Monitoring irritability is essential to assess the effectiveness of interventions for gastroesophageal reflux.
Choice C rationale:
Weight is mentioned in both the initial and follow-up notes. While monitoring weight is essential, there is no indication of weight loss or inadequate weight gain in the follow-up, suggesting that the infant's nutritional status is stable.
Choice D rationale:
Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.
Choice E rationale:
Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.
Choice F rationale:
Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increased heart rate is not a direct indication of the effectiveness of chest physiotherapy treatments in a child with cystic fibrosis. The primary goal of chest physiotherapy is to clear mucus from the airways and improve breathing.
Choice B rationale:
Increased urine output is not directly related to the effectiveness of chest physiotherapy treatments. The focus of chest physiotherapy is on respiratory function and mucus clearance.
Choice C rationale:
Increased expectoration (coughing up mucus) is a positive sign that chest physiotherapy treatments have been effective. Improved clearance of mucus from the airways helps in breathing and reduces the risk of respiratory infections. It indicates that the treatments are helping the child clear the mucus, which is a common problem in cystic fibrosis.
Choice D rationale:
Reduced pain is not the primary goal of chest physiotherapy treatments for cystic fibrosis. While it's essential for the child to be comfortable, the main focus is on improving respiratory function and clearing mucus from the airways.
Correct Answer is C
Explanation
The correct answer is Choice C. Hyporeflexia.
Choice A rationale:
Oliguria, or reduced urine output, can be associated with dehydration or renal impairment, but it is not directly related to hypokalemia (low potassium levels). Hypokalemia primarily affects the muscles and heart rather than urine output.
Choice B rationale:
Hypertension is typically associated with high blood pressure and can be seen in conditions like hyperaldosteronism or Cushing's syndrome. However, it is not a direct result of hypokalemia. Low potassium levels usually lead to other cardiovascular issues such as arrhythmias, but not hypertension.
Choice C rationale:
Hyporeflexia, or decreased reflexes, is a common sign of hypokalemia. Potassium is essential for proper nerve and muscle function. When potassium levels are low, nerve impulses are slowed, leading to diminished reflexes. This symptom aligns with the preschooler's potassium level of 3.2 mEq/L, which is below the normal range.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, low potassium levels can lead to a reduction in gastrointestinal motility, potentially causing constipation or decreased bowel sounds, rather than hyperactivity.
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