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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?

A.

Give your infant an oral rehydration solution.

B.

Bring your baby in to the clinic today.

C.

Try switching to a different formula.

D.

Burp your baby more frequently during feedings.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.

Choice B rationale

Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.

Choice C rationale

Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.

Choice D rationale

Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.

Correct Answer is A

Explanation

Choice A rationale

Testing the urine for ketones is essential for managing type 1 diabetes, especially during illness. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.

Choice B rationale

While notifying the provider if blood glucose levels are over 350 mg/dL is important, it is not the most immediate action required during illness management. High blood glucose levels can indicate poor diabetes control, but ketone testing is more critical during illness to prevent ketoacidosis.

Choice C rationale

Withholding insulin when feeling nauseous is incorrect. Insulin should not be withheld during illness, as blood glucose levels can increase due to stress or infection. Continuing insulin administration is crucial to prevent hyperglycemia and ketoacidosis.

Choice D rationale

Limiting fluid intake during mealtime is not recommended. Proper hydration is essential for overall health and helps manage blood glucose levels. Fluids should be consumed as needed, especially during illness.

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