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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Seizure precautions are necessary due to the risk of seizures in bacterial meningitis.
B. A private room is necessary to reduce the spread of infection to others.
C. Semi-Fowler's position helps reduce intracranial pressure and is appropriate in managing bacterial meningitis.
D. Measuring head circumference every shift is not typically required for a 6-year-old with bacterial meningitis, as it is more relevant in infants where rapid head growth could indicate increased intracranial pressure.
Correct Answer is C
Explanation
A. The pneumococcal polysaccharide vaccine is typically administered to older adults or individuals with certain chronic conditions, not routinely to adolescents.
B. The influenza vaccine is important and should be administered annually but is not specific to pre-college preparation.
C. The meningococcal polysaccharide vaccine is recommended for adolescents, especially those preparing to enter college, as it protects against meningococcal disease, which can spread quickly in communal living settings.
D. The Bacille Calmette-Guérin (BCG) vaccine is used in areas with high tuberculosis incidence and is not a standard immunization for adolescents in the United States.
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