A mother brings her 2-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?

Focusing exclusively on the reported illness

Asking the mother to leave the room after obtaining their history

Obtaining a comprehensive history, including socio-economic data

Reviewing health promotion and maintenance activities

Answer and Explanation

The Correct Answer is C

a) Focusing exclusively on the reported illness: Given the regular visits and the gap since the last well-child visit, it's essential to consider a broader perspective beyond the reported illness.

b) Asking the mother to leave the room after obtaining their history: This situation doesn't suggest the need to exclude the mother from the discussion.

c) Obtaining a comprehensive history, including socio-economic data: This approach considers the child's health within a broader context, taking into account any changes or potential factors influencing the child's health.

d) Reviewing health promotion and maintenance activities: While important, this situation requires a broader assessment due to the gap between visits and a sick visit.

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Correct Answer is A

Explanation

a) Projectile vomiting: A hallmark symptom of pyloric stenosis due to the narrowing of the pyloric sphincter, leading to forceful and projectile vomiting.

b) Watery diarrhea: Not typically associated with pyloric stenosis.

c) Increased urine output: Unrelated to pyloric stenosis, urinary output might vary based on other factors.

d) Bloody stools: Typically not a primary symptom of pyloric stenosis, which primarily affects the passage of food from the stomach.

A. Do not report any pause in respiration unless it's greater than 20 seconds B. Report any neonate with nasal flaring C. Report any pause in respiration greater than 10 seconds D. Report any respiratory rate of 40 or greater

Correct Answer is B

Explanation

A. Do not report any pause in respiration unless it's greater than 20 seconds.Any pause in respiration can be significant in neonates. A pause in breathing, even if less than 20 seconds, should be reported, as it could indicate a potential problem. This option downplays the importance of monitoring respiratory patterns.

B. Report any neonate with nasal flaring.Nasal flaring in a neonate is a sign of respiratory distress. This instruction is essential because nasal flaring indicates the infant is working harder to breathe and may require further evaluation and intervention.

C. Report any pause in respiration greater than 10 seconds.While this is important, nasal flaring is a more immediate and visible sign of respiratory distress that should be reported.

D. Report any respiratory rate of 40 or greater.A respiratory rate of 40 breaths per minute is within the normal range for neonates. Reporting a normal rate would not be necessary and could create unnecessary concern.

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A mother brings her 2-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Expected symptoms in an infant with pyloric stenosis:

Correct Answer is A

Explanation

A nurse delegates the task of neonatal vital sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assigning care?

Correct Answer is B

Explanation

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