A nurse is caring for a 6-week-old infant whose guardian reports intermittent vomiting for several days.

Nurses' Notes

Guardian reports infant has been forcefully vomiting after feedings. Guardian states the emesis is so forceful that it often lands 3 to 4 feet away. Infant is very fussy and rooting and sucks vigorously on a pacifier.

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

(Select All that Apply.).

Implement droplet precautions,

Prepare the infant for surgical correction.

Evaluate the infant's pain level using the FLACC scale.

Monitor the infant's intake and output.

Offer the infant small, frequent feedings of thickened liquids

Plan to administer a plain water enema to the infant

Answer and Explanation

Correct Answer : B,C,D

A. Droplet precautions are typically used for infections transmitted through respiratory droplets, such as influenza or COVID-19. Since the symptoms described are more consistent with pyloric stenosis rather than an infectious disease, droplet precautions are not indicated.

B. The infant's symptoms are indicative of possible hypertrophic pyloric stenosis, a condition where the pylorus (the opening from the stomach to the small intestine) becomes narrowed, leading to forceful vomiting and dehydration. Surgical intervention, such as a pyloromyotomy, is often required to correct this condition.

C. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used to assess pain in infants and young children who cannot verbalize their discomfort. Given the infant's fussiness and symptoms, evaluating pain is crucial to managing the infant's discomfort.

D. Monitoring intake and output is important in an infant with vomiting to assess for dehydration and ensure appropriate fluid balance. This is a key aspect of managing any vomiting-related condition and ensuring the infant receives adequate hydration.

E. In the case of hypertrophic pyloric stenosis, thickened liquids are not recommended. The main treatment is surgical, and feeding modifications alone will not address the underlying condition.

F. A plain water enema is not appropriate for this infant’s symptoms. Hypertrophic pyloric stenosis does not require an enema and may actually worsen the infant's condition.

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Correct Answer is D

Explanation

A. Prone positioning is not recommended post-operatively for abdominal surgery and could exacerbate respiratory issues.

B. While monitoring white blood cell count is important, encouraging lung expansion and preventing complications such as atelectasis is a more immediate priority.

C. The client's pain rating is low and does not necessitate immediate administration of acetaminophen.

D. Encouraging the use of an incentive spirometer helps improve lung expansion, which is crucial to prevent atelectasis and promote proper oxygenation, particularly when breath sounds are diminished.

A. Explain the discharge instructions to the client and parents. B. Educate to place affected leg on pillow props. C. Administer an anti-inflammatory for pain relief. D. Perform a neurovascular assessment

Correct Answer is D

Explanation

A. While explaining discharge instructions is important, it is not the immediate priority following cast application.

B. Educating the client to elevate the leg is important to reduce swelling, but it is not the first priority.

C. Administering pain relief is necessary, but assessing circulation, sensation, and movement is more critical to identify any early signs of complications.

D. Performing a neurovascular assessment is the priority action because it ensures that there is no compromise to blood flow, sensation, or movement in the affected limb, which could indicate complications such as compartment syndrome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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