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Keeping the infant supine is not recommended, as it increases the risk of aspiration and bleeding. The infant should be placed in a side-lying or upright position to facilitate drainage and prevent pressure on the suture line.

Feeding the infant with a spoon for 48 hours is not necessary, as it may cause discomfort and trauma to the palate. The infant can be fed with a special nipple or a syringe with a rubber tip that delivers small amounts of formula or breast milk to the side of the mouth.

Suctioning the mouth with an oral suction tube is contraindicated, as it may damage the palate and cause bleeding or infection. The nurse should use a bulb syringe to gently suction the nose and mouth if needed.

Placing the infant on his right side does not prevent regurgitation and aspiration, as the stomach is higher than the esophagus in this position. This may worsen the symptoms of gastroesophageal reflux.

Placing the infant in a prone position increases the risk of sudden infant death syndrome (SIDS), as it may impair the infant's breathing and oxygenation. This position should be avoided unless prescribed by the provider.

Placing the infant in an infant seat may cause increased abdominal pressure and aggravate the gastroesophageal reflux. This position should be used only for short periods of time and with proper support.

Cranberry juice is not a good choice for a child who has had a tonsillectomy, as it is acidic and may cause pain and irritation to the throat. The nurse should avoid offering citrus juices or carbonated beverages to the child.

Vanilla milkshake is also not a good choice for a child who has had a tonsillectomy, as it is thick and may coat the throat and interfere with healing. The nurse should avoid offering dairy products or foods that are sticky or hard to swallow to the child.

Cubed ice is not a good choice for a child who has had a tonsillectomy, as it may be too cold and cause vasoconstriction and bleeding. The nurse should avoid offering very cold or very hot fluids to the child.

This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.

A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.

This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.

This statement is correct, as maintaining NPO status is a standard intervention for a child with suspected appendicitis. It prevents further irritation of the appendix and prepares the child for possible surgery.

This statement is correct, as monitoring oral temperature every 4 hours is a way to assess for signs of infection and inflammation in a child with suspected appendicitis. The nurse should also monitor for other symptoms such as abdominal pain, nausea, vomiting, and rebound tenderness.

This statement is correct, as medicating the client for pain every 4 hours as needed is a way to provide comfort and relief for a child with suspected appendicitis. The nurse should use a pain scale to evaluate the effectiveness of the medication and report any changes in the pain level or location.

This statement is normal, as an infant who is 2 months old should be alert and responsive to stimuli. The nurse should assess the infant's level of consciousness and responsiveness using the AVPU scale (alert, voice, pain, unresponsive).

This statement is normal, as an infant who is 2 months old should have warm and dry skin and a tone that is appropriate for their ethnicity. The nurse should assess the infant's skin color, temperature, moisture, and turgor.

This statement is normal, as an infant who is 2 months old should have full range of motion in their extremities and no clicks noted. The nurse should assess the infant's muscle strength, tone, and symmetry, and check for any signs of hip dysplasia, such as a positive Barlow or Ortolani test.

This statement is normal, as an infant who is 2 months old should have an axillary temperature between 36.5°C and 37.5°C (97.7°F and 99.5°F). The nurse should assess the infant's temperature using an axillary or tympanic method, as oral and rectal methods are not recommended for infants.

This statement is normal, as an infant who is 2 months old should have a heart rate between 100 and 160 beats per minute. The nurse should assess the infant's heart rate by auscultating the apical pulse for a full minute.

This statement is normal, as an infant who is 2 months old should have a respiratory rate between 25 and 40 breaths per minute. The nurse should assess the infant's respiratory rate by observing the chest movements for a full minute.

Gastroesophageal reflux is a condition in which the lower esophageal sphincter fails to close properly, allowing the stomach contents to flow back into the esophagus. It is common in infants, especially those who are bottle-fed, and usually resolves by 12 months of age. The main symptoms are regurgitation, spitting up, irritability, and poor weight gain.

Celiac disease is a condition in which the immune system reacts to gluten, a protein found in wheat, barley, and rye, and damages the lining of the small intestine. It can affect people of any age, but is usually diagnosed in childhood. The main symptoms are diarrhea, abdominal pain, bloating, weight loss, and failure to thrive.

Lactose intolerance is a condition in which the body lacks the enzyme lactase, which is needed to digest lactose, a sugar found in milk and dairy products. It can affect people of any age, but is more common in adults and certain ethnic groups. The main symptoms are diarrhea, gas, bloating, and abdominal cramps after consuming lactose-containing foods.

This statement is incorrect, as the child should take the enzymes before or with meals, not after. Taking the enzymes after meals may reduce their effectiveness and cause malabsorption of nutrients.

This statement is incorrect, as the child should take the enzymes within 30 minutes before meals, not 2 hours. Taking the enzymes too early may cause them to be inactivated by the stomach acid and lose their function.

This statement is incorrect, as the child does not take the enzymes to improve her metabolism, but to replace the deficient pancreatic enzymes that are needed for digestion. The child has cystic fibrosis, a genetic disorder that affects the exocrine glands and causes thick mucus to block the ducts of the pancreas.

This statement is incorrect, as giving an oral rehydration solution to an infant who is projectile vomiting may worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to stop feeding the infant and seek medical attention.

This statement is incorrect, as burping the baby more frequently during feedings may not prevent the projectile vomiting, which is caused by a mechanical obstruction of the stomach, not by air swallowing. The nurse should assess the parent for signs of pyloric stenosis, such as a palpable olive-shaped mass in the right upper quadrant of the abdomen.

This statement is incorrect, as trying switching to a different formula may not help the infant who is projectile vomiting, which is not related to the type of formula, but to a structural problem in the gastrointestinal tract. The nurse should not suggest changing the formula without consulting the provider.

This statement is incorrect, as montelukast is a leukotriene receptor antagonist that is used for long-term control and prevention of asthma symptoms. It is not effective for acute asthma attacks, as it does not provide immediate bronchodilation.

This statement is incorrect, as budesonide is an inhaled corticosteroid that is used for long-term control and prevention of inflammation in asthma. It is not effective for acute asthma attacks, as it does not provide immediate relief of bronchospasm.

This statement is incorrect, as prednisone is an oral corticosteroid that is used for short-term treatment of severe asthma exacerbations. It is not effective for acute asthma attacks, as it takes several hours to exert its anti-inflammatory effect.

This statement is incorrect, as reports of thirst are not a manifestation of hemorrhage following a tonsillectomy. Thirst may be caused by dehydration, dry mouth, or fever, which are common after surgery.

This statement is incorrect, as mouth breathing is not a manifestation of hemorrhage following a tonsillectomy. Mouth breathing may be due to nasal congestion, pain, or swelling, which are expected after surgery.

This statement is incorrect, as reports of pain are not a manifestation of hemorrhage following a tonsillectomy. Pain is a normal and expected outcome after surgery and should be managed with analgesics and comfort measures.

This statement is incorrect, as the child will not have normal bowel movements immediately after the initial surgery. The surgery involves removing the affected part of the colon and creating a temporary ostomy, which is an opening in the abdomen that allows stool to pass into a bag. The child will need a second surgery to reconnect the bowel and close the ostomy.

This statement is incorrect, as the child will not need a feeding tube after the initial surgery. The child will be able to eat and drink normally, but may need to follow a low-fiber diet to avoid constipation and bowel obstruction.

This statement is incorrect, as the child will not need a urinary catheter after the initial surgery. The child will be able to urinate normally, but may need to drink plenty of fluids to prevent dehydration and urinary tract infections.

Wheat also contains gluten and should be avoided by people with celiac disease for the same reason as barley.

Rice is a gluten-free grain and can be safely consumed by people with celiac disease. Rice is a good source of carbohydrates, fiber, and vitamins.

Potatoes are also gluten-free and can be safely consumed by people with celiac disease. Potatoes are a good source of potassium, vitamin C, and starch.

Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.

Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.

A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.

Offering fluids through a straw is not recommended for a toddler who has had a cleft palate repair, as it can cause suction and pressure in the mouth that can disrupt the sutures. The nurse should offer fluids with a cup or a spoon.

Implementing a soft diet is not appropriate for a toddler who has had a cleft palate repair, as it can cause irritation and infection in the mouth. The nurse should provide clear liquids for the first 24 hr and then advance to full liquids as tolerated.

Administering opioids for pain is not the first choice for a toddler who has had a cleft palate repair, as it can cause respiratory depression and constipation. The nurse should use nonpharmacological methods such as distraction, comfort, and reassurance first, and then administer acetaminophen or ibuprofen as prescribed.

Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.

Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.

Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.

Hypertrophic pyloric stenosis is a condition in which the pyloric sphincter becomes thickened and obstructs the passage of food from the stomach to the duodenum. It causes projectile vomiting, dehydration, and weight loss, but not a palpable mass or bloody stools.

Inguinal hernia is a condition in which a part of the intestine protrudes through a weak spot in the abdominal wall near the inguinal canal. It causes a bulge in the groin area, especially when the infant cries or strains. It does not cause a mass in the upper right quadrant or bloody stools.

Tracheoesophageal fistula is a congenital anomaly in which there is an abnormal connection between the trachea and the esophagus. It causes excessive drooling, choking, coughing, and cyanosis during feeding, but not a palpable mass or bloody stools.

Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.

Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.

Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.

The child has a normal potassium level, as it is within the reference range of 3.5 to 5 mEq/L. Potassium is an electrolyte that helps regulate the fluid balance, nerve impulses, and muscle contractions in the body.

The child has a normal platelet level, as it is within the reference range of 150,000 to 450,000 mm^3^. Platelets are blood cells that help with clotting and prevent bleeding. Sickle cell anemia can cause thrombocytopenia, a low platelet count, due to increased destruction or sequestration of platelets in the spleen.

The child has a normal blood glucose level, as it is within the reference range of 70 to 110 mg/dL. Blood glucose is the main source of energy for the cells in the body. Sickle cell anemia can cause hypoglycemia, a low blood glucose level, due to impaired glucose metabolism, increased glucose utilization, or decreased glucose production.

The child does not have signs of peritonitis and septic shock, such as fever, chills, rigors, tachycardia, hypotension, and abdominal rigidity. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity and organs. Septic shock is a severe infection that causes systemic inflammatory response syndrome and organ dysfunction.

The child does not have signs of pancreatitis and cardiogenic shock, such as elevated serum amylase and lipase, jaundice, dyspnea, crackles, and chest pain. Pancreatitis is an inflammation of the pancreas, an organ that produces digestive enzymes and hormones. Cardiogenic shock is a failure of the heart to pump enough blood to meet the body's needs.

The child does not have signs of peptic ulcer and anaphylactic shock, such as hematemesis, dyspepsia, urticaria, angioedema, and wheezes. Peptic ulcer is a sore in the lining of the stomach or duodenum, caused by factors such as Helicobacter pylori infection, NSAIDs, or stress. Anaphylactic shock is a severe allergic reaction that causes bronchoconstriction, vasodilation, and hypotension.

Decreased respiratory rate is not a finding that indicates the effectiveness of suctioning the tracheostomy. A decreased respiratory rate could be a sign of respiratory depression, fatigue, or hypoxia.

Stable oxygen saturation is not a finding that indicates the effectiveness of suctioning the tracheostomy. A stable oxygen saturation could be maintained even if the tracheostomy is obstructed or infected.

Pink capillary refill is not a finding that indicates the effectiveness of suctioning the tracheostomy. Pink capillary refill is a sign of adequate perfusion and circulation, but it does not reflect the status of the airway.

Skin integrity is not a reliable indicator of fluid loss, as it can be affected by other factors such as infection, trauma, or allergy. Skin integrity can be assessed by checking for turgor, elasticity, and color.

Blood pressure is not a reliable indicator of fluid loss, as it can be influenced by other factors such as cardiac output, vascular resistance, and stress. Blood pressure can be measured by using a sphygmomanometer and a stethoscope.

Respiratory rate is not a reliable indicator of fluid loss, as it can be affected by other factors such as oxygen demand, lung function, and airway obstruction. Respiratory rate can be measured by counting the number of breaths per minute.

Absent bowel sounds are not a finding that indicates perforation of the appendix. Absent bowel sounds could be a sign of ileus, obstruction, or peritonitis, but they are not specific to appendicitis.

Low-grade fever is not a finding that indicates perforation of the appendix. Low-grade fever could be a sign of infection, inflammation, or dehydration, but it is not specific to appendicitis.

Flaccid abdomen is not a finding that indicates perforation of the appendix. Flaccid abdomen could be a sign of muscle relaxation, sedation, or paralysis, but it is not specific to appendicitis.