A nurse is caring for an infant whose guardian reports intermittent vomiting for several days. Findings upon admission:
Which of the following actions should the nurse take? (Select all that apply)
Implement contact precautions.
Measure the infant's head circumference.
Weigh the infant
Monitor the infant's intake and output.
Offer the infant small, frequent feeding of thickened liquids.
Evaluate the infant's pain level using the FACES scale.
Plan to administer a plain water enema to the infant.
Correct Answer : C,D
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.
B. Head circumference is routine for well-baby visits and neurological conditions (e.g., hydrocephalus). It is not related to pyloric stenosis assessment.
C. Regular weighing is crucial to assess for weight loss due to vomiting and dehydration. Monitoring weight helps evaluate the severity of the infant's condition and the effectiveness of ongoing treatment.
D. Tracking intake and output is essential for managing hydration status and ensuring the infant is receiving adequate fluids. It helps in assessing the balance between fluid loss due to vomiting and fluid replacement.
E. This intervention is not appropriate for hypertrophic pyloric stenosis. The primary treatment for this condition is surgical intervention, and feeding changes alone will not resolve the underlying issue.
F. The FACES scale is typically used for older children who can self-report pain. For an infant, alternative pain assessment methods would be used, such as observing behavioral cues.
G. An enema is not indicated for hypertrophic pyloric stenosis and may worsen the infant's condition. The focus should be on hydration and surgical preparation rather than enemas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Obtaining a blood culture is important but is not the immediate priority when a transfusion reaction is occurring.
B. Stopping the transfusion is the first step in managing a transfusion reaction to prevent further exposure to the allergen or irritant causing the symptoms.
C. Slowing the transfusion rate might not be sufficient if a reaction is occurring; stopping it is crucial.
D. Providing a diuretic is not relevant to the management of an acute transfusion reaction.
Correct Answer is C
Explanation
A. While play therapy can be beneficial, it is not the primary focus for a 10-year-old child’s psychosocial needs related to Erikson’s stage.
B. Encouraging visits from friends supports the child's need for social interaction, which is important for psychosocial development during hospitalization.
C. Encouraging the child to complete school work helps maintain a sense of normalcy and supports the child’s need for achievement and competence, which is central to Erikson’s stage of industry vs. inferiority.
D. Consistency is important, and varying the child's schedule may add stress rather than support their psychosocial needs.
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