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 A
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.
Correct Answer is D
Explanation
Choice A rationale
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.