A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?
Alert and responsive to stimuli
Skin warm and dry and tone is appropriate for ethnicity
Abdomen distended with visible mass noted in right upper quadrant
Full range of motion in extremities, no clicks noted
The Correct Answer is C
Choice A reason: This statement is normal, as an infant who is 2 months old should be alert and responsive to stimuli. The nurse should assess the infant's level of consciousness and responsiveness using the AVPU scale (alert, voice, pain, unresponsive).
Choice B reason: This statement is normal, as an infant who is 2 months old should have warm and dry skin and a tone that is appropriate for their ethnicity. The nurse should assess the infant's skin color, temperature, moisture, and turgor.
Choice C reason: This statement is abnormal, as an infant who is 2 months old should not have a distended abdomen or a visible mass in the right upper quadrant. This could indicate a serious condition such as a liver tumor, a bowel obstruction, or a hernia. The nurse should report this finding to the provider and monitor the infant for signs of pain, vomiting, or jaundice.
Choice D reason: This statement is normal, as an infant who is 2 months old should have full range of motion in their extremities and no clicks noted. The nurse should assess the infant's muscle strength, tone, and symmetry, and check for any signs of hip dysplasia, such as a positive Barlow or Ortolani test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement indicates a need for clarification, as sodium biphosphate/sodium phosphate is a laxative that can cause bowel perforation in a child with appendicitis. The nurse should question this prescription and avoid giving it to the child.
Choice B reason: This statement is correct, as maintaining NPO status is a standard intervention for a child with suspected appendicitis. It prevents further irritation of the appendix and prepares the child for possible surgery.
Choice C reason: This statement is correct, as monitoring oral temperature every 4 hours is a way to assess for signs of infection and inflammation in a child with suspected appendicitis. The nurse should also monitor for other symptoms such as abdominal pain, nausea, vomiting, and rebound tenderness.
Choice D reason: This statement is correct, as medicating the client for pain every 4 hours as needed is a way to provide comfort and relief for a child with suspected appendicitis. The nurse should use a pain scale to evaluate the effectiveness of the medication and report any changes in the pain level or location.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as montelukast is a leukotriene receptor antagonist that is used for long-term control and prevention of asthma symptoms. It is not effective for acute asthma attacks, as it does not provide immediate bronchodilation.
Choice B reason: This statement is incorrect, as budesonide is an inhaled corticosteroid that is used for long-term control and prevention of inflammation in asthma. It is not effective for acute asthma attacks, as it does not provide immediate relief of bronchospasm.
Choice C reason: This statement is incorrect, as prednisone is an oral corticosteroid that is used for short-term treatment of severe asthma exacerbations. It is not effective for acute asthma attacks, as it takes several hours to exert its anti-inflammatory effect.
Choice D reason: This statement is correct, as albuterol is a short-acting beta2 agonist that is used for quick relief of acute asthma symptoms. It provides rapid bronchodilation by relaxing the smooth muscles of the airways.
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