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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

Explanation

A. Wash bed linens in cold water. Washing bed linens in cold water is ineffective for killing pinworm eggs. Hot water should be used to properly sanitize linens and kill the eggs.
B. Clean the bathroom with bleach solution. While cleaning the bathroom with bleach can help reduce contamination, it is not a primary or effective measure for preventing pinworm spread and reinfection in a household setting.
C. Keep children's nails short. Keeping nails short reduces the likelihood of the child scratching the perianal area, where pinworm eggs are deposited, and then ingesting the eggs through hand-to-mouth contact. This helps prevent the spread and reinfection of pinworms.
D. Dress child in loose-fitting underwear. Loose-fitting underwear does not specifically help in preventing the spread or reinfection of pinworms. Tight-fitting underwear may actually be better to prevent the spread of eggs to other surfaces.

A. Hypertension B. Polyuria C. Orange-tinged urine D. Periorbital edema

Correct Answer is D

Explanation

A. Hypertension: Hypertension is not typically associated with nephrotic syndrome unless there are underlying kidney complications.
B. Polyuria: Polyuria (increased urine output) is not typically seen in nephrotic syndrome, which is characterized by proteinuria and edema.
C. Orange-tinged urine: Orange-tinged urine suggests the presence of blood or bilirubin, which is not typically associated with nephrotic syndrome.
D. Periorbital edema: Periorbital edema (swelling around the eyes) is a common manifestation of nephrotic syndrome due to fluid retention.

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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.