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 : B,C,D
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario.
B. This is important for monitoring for signs of increased intracranial pressure due to potential dehydration and electrolyte imbalances. In cases of severe vomiting and dehydration, monitoring head circumference can help assess the impact on brain hydration status.
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. Pyloric stenosis causes projectile vomiting and dehydration due to gastric outlet obstruction, not inadequate motility of the intestine.
B. Hirschsprung's disease (congenital aganglionic megacolon) leads to inadequate motility of part of the intestine and results in a mechanical obstruction.
C. Encopresis refers to the involuntary defecation in children, typically related to constipation, not motility issues.
D. Enterocolitis is inflammation of the intestine and can cause symptoms such as diarrhea, but it is not characterized by inadequate motility of the intestine.
Correct Answer is A
Explanation
A. Testing urine for ketones is crucial during illness because it helps in early detection of diabetic ketoacidosis, which can be life-threatening.
B. Withholding insulin is dangerous during illness, as the body may require more insulin, not less.
C. While it is important to notify the provider if blood glucose levels are elevated, monitoring for ketones takes precedence to prevent complications.
D. Limiting fluid intake is not recommended, as fluids are essential for maintaining hydration and helping to manage blood glucose levels during illness.
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