A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?
Give your infant an oral rehydration solution.
Bring your baby in to the clinic today.
Try switching to a different formula.
Burp your baby more frequently during feedings.
The Correct Answer is B
Choice A rationale
Giving an oral rehydration solution is not appropriate without first assessing the infant. Projectile vomiting in a 2-month-old could indicate a serious condition such as pyloric stenosis, which requires medical evaluation.
Choice B rationale
Bringing the baby to the clinic today is the appropriate response. Projectile vomiting in an infant can be a sign of a serious condition that requires prompt medical evaluation and treatment.
Choice C rationale
Switching to a different formula is not appropriate without first assessing the infant. Projectile vomiting could indicate a serious condition that needs to be evaluated by a healthcare provider.
Choice D rationale
Burping the baby more frequently during feedings may help with minor feeding issues, but it is not appropriate advice for projectile vomiting. The infant needs to be evaluated by a healthcare provider to determine the cause of the vomiting.
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Correct Answer is B
Explanation
Choice A rationale
Restraining the child’s arms during a seizure is not recommended. Restraint can cause injury to the child and does not prevent the seizure from occurring. Instead, the focus should be on ensuring the child’s safety by removing any nearby objects that could cause harm.
Choice B rationale
Positioning the child laterally (on their side) is the correct action. This position helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration. It also facilitates better breathing and prevents the tongue from obstructing the airway.
Choice C rationale
Attempting to stop the seizure is not advisable. Seizures typically run their course and attempting to stop them can cause more harm than good. The nurse should focus on ensuring the child’s safety and monitoring the seizure’s duration and characteristics.
Choice D rationale
Using a padded tongue blade is outdated and not recommended. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or airway. It is better to ensure the child’s safety by positioning them laterally and monitoring their airway.
Correct Answer is D
Explanation
Choice A rationale
A storybook about a child who has diabetes can be helpful in educating the child about their condition and normalizing their experience. However, it may not be as effective in addressing the immediate distress caused by an insulin injection. Therapeutic play that directly involves the injection experience can be more beneficial in helping the child cope with their fear and anxiety.
Choice B rationale
A period of play in the playroom can provide a distraction and help the child relax. However, it does not specifically address the child’s distress related to the insulin injection. Therapeutic play that involves role-playing the injection process can be more effective in helping the child understand and cope with the procedure.
Choice C rationale
A video game can serve as a distraction and help the child relax. However, it does not directly address the child’s fear and anxiety related to the insulin injection. Therapeutic play that involves role-playing the injection process can be more effective in helping the child understand and cope with the procedure.
Choice D rationale
Using a needleless syringe and a doll allows the child to engage in therapeutic play that simulates the experience of receiving an insulin injection. This type of play helps the child understand the procedure, reduces fear and anxiety, and provides a sense of control over the situation. It is a direct and effective way to help the child cope with the distress caused by the injection.