A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit.

The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks.

Parents report the vomiting is now forceful and projectile (“like a volcano erupting”) immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry.

The infant has been receiving a cow’s milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks.

The last weight in the pediatrician’s office is 3.54kg (8 lb). No other significant medical or surgical history.

What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client’s progress?

Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits

Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency

Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency

Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions

Answer and Explanation

The Correct Answer is B

Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.

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Correct Answer is D

Explanation

Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.

A. Yogurt B. Gelatin C. Strained soup D. Pureed fruit

Correct Answer is B

Explanation

Choice B rationale
Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature.
Choice A rationale
Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature.
Choice C rationale
Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed.
Choice D rationale
Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?

Correct Answer is B

Explanation

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

A nurse is collecting data from an infant who has otitis media. Which of the following findings should the nurse expect?

Which client on an acute care pediatric unit requires the nurse’s immediate attention?

A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)

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The Health Care Provider prescribes Amoxicillin at a dosage of 35mg/kg/dose for a child who weighs 34 lbs. and has Otitis Media. The medication is available in a suspension of 50 mg/ml. What is the total daily dosage in ml for this child?