The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucous and a small amount of blood, stating "her stool kind of looks like currant jelly". She asks the nurse what she should do. Select the nurse's best response.
Many infants display these symptoms when they develop an allergy to their formula. Try switching to a soy based formula.
Try feeding the infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency department for some tests and intravenous rehydration.
Do not worry about the blood and mucous in the stool: it is not unusual for infants to have blood in their stools because their intestines are more sensitive.
Your infant will need to have some tests in the emergency room to determine if anything serious is going on.
The Correct Answer is D
Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.
Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.
Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.
Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Watching for signs of cyanosis and administering high dose steroids are not the first steps in managing infective endocarditis. Cyanosis is a late sign of hypoxia and steroids are not indicated for this condition.
Choice B reason: This is the correct choice. Obtaining blood cultures, administering high dose antibiotics, and assessing for cardiac decompensation are the priority interventions for a child with infective endocarditis. Blood cultures are needed to identify the causative organism and guide antibiotic therapy. High dose antibiotics are needed to eradicate the infection and prevent further damage to the heart valves. Cardiac decompensation is a serious complication of infective endocarditis that can lead to heart failure and shock.
Choice C reason: This is not a good choice. Starting high dose antibiotics, obtaining serial blood cultures, and putting the child on high flow oxygen are not the best order of management for infective endocarditis. Blood cultures should be obtained before starting antibiotics to avoid false negative results. High flow oxygen may not be necessary unless the child has signs of hypoxia or respiratory distress.
Choice D reason: This is not a good choice. Obtaining CBC, CXR and starting child on high dose aspirin are not the first steps in managing infective endocarditis. CBC and CXR are useful tests to monitor the infection and the cardiac function, but they are not as urgent as blood cultures. High dose aspirin is not recommended for infective endocarditis as it can increase the risk of bleeding.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as Tanner staging is not based on chronological age, but on the physical development of the child. Children may enter and progress through puberty at different ages, depending on their genetic, environmental, and nutritional factors.
Choice B reason: This statement is incorrect, as Tanner staging is not based on the sexual behavior of the child, but on the appearance of the external genitalia, breasts, and pubic hair. Sexual behavior is influenced by many factors, such as social, cultural, and psychological factors, and does not necessarily correlate with the stage of puberty.
Choice C reason: This statement is incorrect, as Tanner staging is not based on the increase in height and weight, but on the maturation of the reproductive organs and secondary sex characteristics. Height and weight are affected by many factors, such as nutrition, health, and genetics, and do not necessarily reflect the stage of puberty.
Choice D reason: This statement is correct, as Tanner staging is based on the predictable stages of puberty that are based on primary and secondary sexual characteristics. Primary sexual characteristics are the development of the internal and external reproductive organs, such as the ovaries, testes, uterus, penis, and vagina. Secondary sexual characteristics are the changes that occur in other parts of the body, such as the breasts, pubic hair, axillary hair, voice, and body shape.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today