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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Measure the infant's head circumference.

Weigh the infant.

Monitor intake and output.

Offer small frequent feedings of thickened liquids.

Evaluate serum electrolyte levels.

Plan to administer a plain water enema.

Implement contact precautions.

Answer and Explanation

Correct Answer : B,C,E

A. Measure the infant's head circumference. Measuring head circumference is a standard part of routine well-child exams and growth monitoring, but it is not directly relevant to the current diagnosis of hypertrophic pyloric stenosis. The immediate clinical focus is on the gastrointestinal symptoms and associated dehydration.
B. Weigh the infant. Weighing the infant is crucial for monitoring weight loss and assessing hydration status. Infants with hypertrophic pyloric stenosis are at risk of dehydration and malnutrition due to frequent, forceful vomiting. Regular weight checks help in evaluating the effectiveness of treatment and the nutritional status of the infant.
C. Monitor intake and output. Monitoring intake and output is vital in this scenario to assess the infant's hydration status and kidney function. Given the forceful vomiting, there's a high risk of dehydration, as indicated by the dry mucous membranes, depressed fontanel, and reduced urine output. Accurate measurement helps guide fluid replacement therapy.
D. Offer small frequent feedings of thickened liquids. Offering feedings, even of thickened liquids, is inappropriate in this situation because the infant requires surgical intervention for pyloric stenosis. Continued feeding may exacerbate vomiting and dehydration. Instead, the infant should be kept NPO (nothing by mouth) to prepare for surgery and prevent further complications.
E. Evaluate serum electrolyte levels: Infants with hypertrophic pyloric stenosis often develop electrolyte imbalances such as hypokalemia, hypochloremia, and metabolic alkalosis due to prolonged vomiting. Evaluating serum electrolytes is essential to identify and correct these imbalances, which are critical to stabilizing the infant before surgical intervention.
F. Plan to administer a plain water enema. A plain water enema is not indicated and is inappropriate for treating hypertrophic pyloric stenosis. The issue is not related to bowel movements or lower gastrointestinal obstruction, but rather to the pyloric sphincter in the stomach, which requires surgical correction.
G. Implement contact precautions. Contact precautions are typically used to prevent the spread of infectious diseases. Hypertrophic pyloric stenosis is not an infectious condition but a structural anomaly. Thus, there is no need for contact precautions in this context.

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Correct Answer is ["C","D","E"]

Explanation

A. Excessive hair growth: Hair loss, not excessive hair growth, is a common side effect of chemotherapy.
B. Increased appetite. Chemotherapy often causes nausea, vomiting, and reduced appetite, not an increase in appetite.
C. Fatigue. Fatigue is a common side effect of chemotherapy due to its impact on the body, including reduced blood counts and overall systemic stress.
D. Possible infections: Chemotherapy weakens the immune system, increasing the risk of infections. The nurse will monitor the child for signs of infection and implement measures to prevent them, like proper hand hygiene and maintaining a clean environment.
E. Easy bruising: Chemotherapy can affect blood clotting, making the child more susceptible to bruising. The nurse will educate the parents and child about precautions to minimize bruising risks

A. Give the child 1⁄2 cup of orange juice to drink. B. Call the dietary department and ask that the lunch tray be delivered early. C. Contact the physician. D. Obtain a blood glucose reading

Correct Answer is A

Explanation

A. Give the child 1⁄2 cup of orange juice to drink. These symptoms indicate hypoglycemia, a common early complication of diabetes treatment. Orange juice contains quick-acting sugars that can rapidly raise blood glucose levels and alleviate symptoms. This is the immediate action to manage the child's symptoms.
B. Call the dietary department and ask that the lunch tray be delivered early. Delayed action compared to treating the immediate hypoglycemia.
C. Contact the physician. While eventually necessary, immediate treatment of hypoglycemia takes precedence.
D. Obtain a blood glucose reading. Important to confirm hypoglycemia but not as urgent as providing immediate treatment.

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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission: Exhibits Which of the following actions should the nurse take? Select all that apply.

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A nurse is assisting in the care of an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:

Exhibits

Which of the following actions should the nurse take? Select all that apply.