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 C
Explanation
Choice A rationale
Over-riding suture lines are not a typical manifestation of hydrocephalus. This condition involves the accumulation of cerebrospinal fluid within the brain’s ventricles, leading to increased intracranial pressure.
Choice B rationale
A backward sloping appearance of the forehead is not associated with hydrocephalus. This condition typically presents with an enlarged head circumference due to fluid accumulation.
Choice C rationale
Dilated scalp veins are a common manifestation of hydrocephalus. The increased intracranial pressure causes the veins to become more prominent and visible.
Choice D rationale
Hypertension is not a primary symptom of hydrocephalus in newborns. The condition primarily affects the brain and skull, leading to symptoms like an enlarged head, bulging fontanelles, and dilated scalp veins.
Correct Answer is B
Explanation
Choice A rationale
Loosening restrictive clothing can help ensure the child is comfortable and can breathe easily during a seizure. However, it is not the priority action. The primary concern during a tonic- clonic seizure is to maintain the child’s airway and prevent aspiration, especially if the child is vomiting.
Choice B rationale
Positioning the child side-lying is the priority action. This position helps maintain an open airway and allows any vomit or secretions to drain out of the mouth, reducing the risk of aspiration.
Choice C rationale
Placing a pillow under the child’s head can provide comfort and prevent head injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
Choice D rationale
Clearing the area of hazards is important to prevent injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.