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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 A

Explanation

A. A barium enema: A barium enema is both diagnostic and therapeutic for intussusception in many cases. It helps to diagnose the condition by visualizing the telescoped intestine and can also often reduce the intussusception by hydrostatic pressure.
B. IV fluids until the spasms subside: IV fluids are important for managing dehydration and maintaining hydration but do not directly treat intussusception.
C. Immediate surgery: Surgery may be necessary if non-operative reduction methods fail or if there are complications like bowel necrosis or perforation. However, it is not the first-line treatment choice.
D. Gastric lavage: Gastric lavage (stomach pumping) is not indicated for the treatment of intussusception.

A. Require that the child have antibiotic coverage. B. Should be delayed. C. Can interfere with the treatment for nephrosis. D. Can be given in smaller, divided doses.

Correct Answer is B

Explanation

A. Require that the child have antibiotic coverage. This answer is incorrect because immunizations do not typically require antibiotic coverage.
B. Should be delayed. Prednisone can suppress the immune response, potentially reducing the effectiveness of vaccines. Therefore, immunizations should be delayed until the child has completed the course of prednisone and their immune system has recovered.
C. Can interfere with the treatment for nephrosis. While prednisone can be part of nephrotic syndrome treatment, immunizations are not known to interfere directly with this treatment.
D. Can be given in smaller, divided doses. This answer is incorrect because the issue isn't about the size or frequency of the vaccine doses but rather about the timing relative to the child's immunosuppressive 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.