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 C
Explanation
A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.
The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a different issue.
The presence of an infectious blood-borne disease cannot be determined from this test.
The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.
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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