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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Myelomeningocele is a type of spina bifida where there is a protrusion of the meninges and spinal cord through a defect in the vertebrae. This condition can result in partial to complete paralysis in the lower extremities due to the involvement of the spinal cord.

B. A unilateral port-wine birthmark is typically associated with conditions like Sturge-Weber syndrome, not myelomeningocele.

C. A protruding sac containing abdominal contents is characteristic of omphalocele, not myelomeningocele.

D. Fusion of cranial suture lines is not associated with myelomeningocele but rather with craniosynostosis.

A. Low-fat yogurt with blueberries and granola B. Cheese, banana slices, rice cakes, and whole milk C. Eggs, bacon, rye toast, and lactose-free milk D. Egg, cheese, and sausage wrapped in a flour tortilla

Correct Answer is B

Explanation

A. Granola often contains gluten, so this meal would not be suitable for someone with celiac disease.

B. Cheese, banana slices, rice cakes, and whole milk are gluten-free and appropriate for a child with celiac disease.

C. Rye toast contains gluten, which is contraindicated for someone with celiac disease.

D. Flour tortillas generally contain gluten, so this meal is not appropriate for someone with celiac disease.

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Naxlex Comprehensive Predictor Exams

A newborn has been admitted to the intensive care unit with a diagnosis of myelomeningocele. The nurse could expect which of the following with the disorder?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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