The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?
Feed one ounce of formula to correct hypoglycemia.
Administer a prescribed analgesia for pain.
Provide additional blankets to increase body temperature.
Increase IV infusion rate for rehydration.
The Correct Answer is B
The infant's symptoms are consistent with postoperative pain, which can be expected following a surgical procedure like pyloromyotomy. The PN should administer the prescribed analgesic medication to relieve the infant's discomfort and pain. It is crucial to manage pain appropriately in infants to promote healing, improve feeding tolerance, and prevent complications.
Option A is not appropriate as the infant's symptoms are not indicative of hypoglycemia.
Option C is not appropriate as the infant's symptoms do not indicate hypothermia.
Option D is not appropriate as the infant's symptoms do not indicate dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The practical nurse (PN) should obtain a serum glucose level to assess the client's blood sugar level, which can help to determine if the client is experiencing hyperglycemia or diabetic ketoacidosis (DKA). Anorexia, drowsiness, and polydipsia, along with the reported frequent urination and bedwetting, are symptoms of hyperglycemia or DKA.
Offering age-appropriate toys (B) or suggesting diapers for bedtime use (C) are not appropriate actions for the PN to take in this situation.
Bringing orange juice and crackers (D) may help to increase the client's blood sugar level in the short term, but it does not address the underlying issue and may exacerbate the client's symptoms if she is experiencing hyperglycemia or DKA.
Correct Answer is B
Explanation
This finding may indicate a potential cardiac issue that needs immediate medical atention. Projectile vomiting and excessive hunger in a young infant may be signs of pyloric stenosis, a condition in which the muscle between the stomach and small intestine thickens, making it difficult for food to pass through.
Hyperactive gastric sounds may be present with vomiting, but it is not an immediate concern.
Crying without tears may be a sign of dehydration, but it is not an immediate concern.
Underweight for age is a concern but it is not a finding that requires immediate intervention.
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