A 2-month-old infant with hypertrophic pyloric stenosis is receiving parenteral fluids for rehydration and decompression of the stomach while waiting for surgical repair. To maintain normal growth and development of the child during this period, which action should the nurse include in the plan of care?

Ensure placement of the nasogastric tube with an abdominal x-ray.

Use sterile water for gastric lavage.

Offer a pacifier for non-nutritive sucking.

Speak to the healthcare provider about instituting physical therapy.

Answer and Explanation

The Correct Answer is C

A. Ensuring the correct placement of the nasogastric tube with an abdominal x-ray is important for treatment but does not address the infant's developmental needs.

B. Using sterile water for gastric lavage may be necessary for stomach decompression but does not directly support the infant's growth and development.

C. Offering a pacifier for non-nutritive sucking provides comfort and helps maintain the infant’s sucking reflex, which is crucial for feeding and oral development.

D. Physical therapy is not relevant for a 2-month-old infant with hypertrophic pyloric stenosis and does not address immediate developmental needs.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Substituting natural fruit juices for carbonated drinks can help reduce the intake of purines and decrease the risk of gout attacks. Carbonated drinks can contribute to dehydration and worsen gout.

B. High protein foods can increase uric acid levels and exacerbate gout, so this is not a recommended dietary practice for managing gout.

C. Reporting right upper quadrant discomfort is important for liver function monitoring but not directly related to the management of gout symptoms.

D. Using an electric heating pad might provide temporary relief but does not address the underlying issue of uric acid levels or dietary management.

Correct Answer is []

Explanation

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client reports the left knee is swollen and extremely painful to touch. Which instruction should the nurse include in the discharge teaching?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Patient Data Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?