A nurse is caring for an infant whose guardian reports intermittent vomiting for several days.
Findings upon admission:
Nurses Notes
Guardian reports infant has been forcefully vomiting after feedings. Guardian states the emesis is so forceful that it often lands 3 to 4 feet away. Infant is very fussy and rooting and sucks vigorously on a pacifier.
Vital Signs
Axillary temperature: 38.2° C (100.8° F)
Heart rate: 152/min
Respiratory rate: 30/min
Physical Examination
Mucus membranes are dry. Anterior fontanel depressed and soft. Small amount of urine noted in the diaper, which is dark in color. Upper portion of the abdomen is distended. Bowel sounds auscultated in all four quadrants. Palpable olive-shaped mass noted in the right mid-abdominal region.
Diagnostic Results
Ultrasound examination of the abdomen shows a mass that encircles the pyloric canal consistent with hypertrophic pyloric stenosis.
Which of the following actions should the nurse take? (Select all that apply)
Implement contact precautions.
Measure the infant's head circumference.
Weigh the infant
Monitor the infant's intake and output.
Offer the infant small, frequent feeding of thickened liquids.
Evaluate the infant's pain level using the FACES scale.
Plan to administer a plain water enema to the infant.
Correct Answer : B,C,D
Rationale:
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.
B. This is important for monitoring for signs of increased intracranial pressure due to potential dehydration and electrolyte imbalances. In cases of severe vomiting and dehydration, monitoring head circumference can help assess the impact on brain hydration status.
C. Regular weighing is crucial to assess for weight loss due to vomiting and dehydration. Monitoring weight helps evaluate the severity of the infant's condition and the effectiveness of ongoing treatment.
D. Tracking intake and output is essential for managing hydration status and ensuring the infant is receiving adequate fluids. It helps in assessing the balance between fluid loss due to vomiting and fluid replacement.
E. This intervention is not appropriate for hypertrophic pyloric stenosis. The primary treatment for this condition is surgical intervention, and feeding changes alone will not resolve the underlying issue.
F. The FACES scale is typically used for older children who can self-report pain. For an infant, alternative pain assessment methods would be used, such as observing behavioral cues.
G. An enema is not indicated for hypertrophic pyloric stenosis and may worsen the infant's condition. The focus should be on hydration and surgical preparation rather than enemas.
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View Related questions
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. The DTaP vaccine is recommended at 15-18 months, so it would be appropriate to administer it to a 1-year-old child.
B. The rotavirus vaccine is typically given earlier, before the child reaches 1 year of age.
C. The varicella (chickenpox) vaccine is given between 12-15 months of age, so it is appropriate for a 1-year-old.
D. The HPV vaccine is usually administered starting at age 11-12 years, not at 1 year.
E. The MMR (measles, mumps, rubella) vaccine is recommended between 12-15 months of age, making it appropriate for a 1-year-old.
Correct Answer is A
Explanation
Rationale:
A. Placing the child in an upright position helps keep the airway open and can ease breathing difficulties associated with epiglottitis.
B. Obtaining a throat culture can be dangerous in suspected epiglottitis due to the risk of airway obstruction; management should focus on stabilization.
C. Transporting the child to radiology may further compromise the airway and should be avoided unless absolutely necessary.
D. Visualizing the epiglottis with a tongue depressor can trigger airway obstruction and should be avoided in suspected epiglottitis.