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.).

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.