A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first?
Initiate a prescribed IV for parenteral fluid.
Feed the infant 3 ounces of Isomil.
Give the infant 5% dextrose in water orally.
Insert a nasogastric tube for feeding.
The Correct Answer is A
The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.
Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.
Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Children usually resume their toileting behaviors when they leave the hospital.
Choice A rationale:
While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.
Choice B rationale:
Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.
Choice C rationale:
Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.
Choice D rationale:
This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment.Once they return home, they typically resume their previous toileting habits.
Correct Answer is ["A","C","D","E"]
Explanation
Certain medications can contribute to constipation as a side effect. Reviewing the client's medication list will help identify any potential medications that may be causing or exacerbating constipation.
Understanding the client's current approach to managing constipation, such as dietary changes, laxative use, or other remedies, will provide insight into their self-care practices and effectiveness of current interventions.
Diet plays a crucial role in bowel regularity. Assessing the client's dietary habits, including fiber intake and hydration, can help identify potential factors contributing to constipation.
Physical activity and exercise promote bowel regularity by stimulating intestinal motility. Evaluating the client's level of physical activity and exercise routine can provide information on their overall mobility and potential impact on bowel function.
The next scheduled visit with the healthcare provider may be important for the overall management of the client's health but may not be directly related to formulating a plan of care specifically for constipation.
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