A nurse is caring for a 4-month-old infant in the outpatient setting.
Which of the following should the nurse identify as unexpected findings? Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
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Body system
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Findings
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Vital Signs
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Temperature 36.9°C (98.4° F) Heart rate 162/min Respiratory rate 28/min Oxygen saturation 97% on room air |
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Gastrointestinal |
Also spits up after every feeding, sometimes forcefully. Infant is formula fed and recently began refusing some feedings. Bowel sounds normoactive. Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus. Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz). |
Temperature 36.9°C (98.4° F)
Heart rate 162/min
Respiratory rate 28/min
Also spits up after every feeding, sometimes forcefully
Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus
Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz)
The Correct Answer is ["B","D","E"]
Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.
Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.
Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F","G","H"]
Explanation
A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.
Correct Answer is D
Explanation
A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.
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