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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["B","D"]
Explanation
Rationale:
A. Nighttime symptoms occurring twice a month is more characteristic of intermittent asthma rather than mild persistent asthma, which might present with nighttime symptoms more frequently.
B. In mild persistent asthma, the peak expiratory flow (PEF) is typically greater than or equal to 80% of the predicted value, indicating relatively good control of asthma symptoms.
C. Continuous symptoms throughout the day are not typical for mild persistent asthma; symptoms usually occur intermittently.
D. Minor limitations with normal activity are expected in mild persistent asthma, as the condition can cause some restrictions in daily activities but not severe impairments.
E. Daytime symptoms occurring more than twice a week align with moderate persistent asthma, not mild persistent asthma.
Correct Answer is C
Explanation
Rationale:
A. The pneumococcal polysaccharide vaccine is typically administered to older adults or individuals with certain chronic conditions, not routinely to adolescents.
B. The influenza vaccine is important and should be administered annually but is not specific to pre-college preparation.
C. The meningococcal polysaccharide vaccine is recommended for adolescents, especially those preparing to enter college, as it protects against meningococcal disease, which can spread quickly in communal living settings.
D. The Bacille Calmette-Guérin (BCG) vaccine is used in areas with high tuberculosis incidence and is not a standard immunization for adolescents in the United States.