An infant has been admitted to the pediatric unit with a diagnosis of pyloric stenosis. What would the nurse expect in the plan of care for this client?
Administration of analgesic medication
Preparation for surgical correction
Assistance in doing a barium enema on infant
Beginning thickened feedings with rice cereal
The Correct Answer is B
Rationale:
A. While pain management is important, the primary treatment for pyloric stenosis is surgical correction, not just analgesic medication.
B. Preparation for surgical correction, specifically a pyloromyotomy, is the standard treatment for pyloric stenosis to relieve the obstruction.
C. A barium enema is not used in the diagnosis or treatment of pyloric stenosis; it is typically used to diagnose other gastrointestinal conditions.
D. Thickened feedings with rice cereal are not indicated for pyloric stenosis and would not resolve the obstruction.
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Correct Answer is D
Explanation
Rationale:
A. While explaining discharge instructions is important, it is not the immediate priority following cast application.
B. Educating the client to elevate the leg is important to reduce swelling, but it is not the first priority.
C. Administering pain relief is necessary, but assessing circulation, sensation, and movement is more critical to identify any early signs of complications.
D. Performing a neurovascular assessment is the priority action because it ensures that there is no compromise to blood flow, sensation, or movement in the affected limb, which could indicate complications such as compartment syndrome.
Correct Answer is A
Explanation
Rationale:
A. Keeping a dedicated thermometer in the toddler's room is an appropriate infection control measure to prevent cross-contamination with other patients.
B. RSV is primarily transmitted through droplet and contact, not airborne, so contact and droplet precautions are more appropriate than airborne precautions.
C. Nebulized racemic epinephrine is not typically used for RSV; it is more commonly used for croup. Treatment for RSV may include supportive care such as hydration and oxygen therapy.
D. While monitoring pulse oximetry is important, assessing it every 3 hours might be insufficient. Continuous monitoring may be more appropriate depending on the severity of the illness.