A nurse in a pediatrician's office is caring for an infant.
Drag words from the choices below to fill in each blank in the following sentence.
The infant is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
1. Failure to thrive: The infant has poor weight gain despite being hungry after vomiting. Projectile vomiting, as described, often leads to insufficient caloric intake, putting the infant at risk for failure to thrive.
2. Dehydration: Repeated vomiting results in fluid loss, putting the infant at high risk of dehydration, which is common in conditions like pyloric stenosis, suspected here due to the symptoms and palpable abdominal mass.
3. Intussusception typically presents with intermittent, severe abdominal pain, "currant jelly" stools, and sometimes a sausage-shaped mass, which are not noted in this scenario.
4. Meckel diverticulum can cause painless rectal bleeding or obstruction symptoms but is not associated with projectile vomiting or a palpable mass.
5. Hirschsprung disease presents with failure to pass meconium, abdominal distension, and chronic constipation rather than the projectile vomiting seen here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.
Correct Answer is A
Explanation
A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.
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