A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?

Plan for nurses to provide the feedings.

Report this finding to the health care provider.

Assure the mother that this is a normal finding.

Tell the mother it is all right to feel anxious.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.

Choice B rationale:

Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.

Choice C rationale:

Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.

Choice D rationale:

Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.

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Correct Answer is D

Explanation

Choice A rationale:

The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.

Choice B rationale:

The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.

Choice C rationale:

The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.

Choice D rationale:

The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.

A. Monitor breathing pattern at 15-minute intervals. B. Insert indwelling Foley catheter for straight drainage. C. IV D5/45 NS at 100 mL/hr. D. Syrup of ipecac 30 mL, po, Stat.

Correct Answer is D

Explanation

Choice A rationale:

Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.

Choice B rationale:

Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.

Choice C rationale:

Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.

Choice D rationale:

The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.

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A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 3-year-old patient. Which behavior is developmentally appropriate for this patient?

Correct Answer is D

Explanation

A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?

Correct Answer is D

Explanation

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