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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as the child will not have normal bowel movements immediately after the initial surgery. The surgery involves removing the affected part of the colon and creating a temporary ostomy, which is an opening in the abdomen that allows stool to pass into a bag. The child will need a second surgery to reconnect the bowel and close the ostomy.

Choice B reason: This statement is incorrect, as the child will not need a feeding tube after the initial surgery. The child will be able to eat and drink normally but may need to follow a low-fiber diet to avoid constipation and bowel obstruction.

Choice C reason: This statement is incorrect, as the child will not need a urinary catheter after the initial surgery. The child will be able to urinate normally but may need to drink plenty of fluids to prevent dehydration and urinary tract infections.

Choice D reason: This statement is correct, as the child's ostomy is only temporary and will be closed in a second surgery. The parent should be glad that the child will eventually have a normal bowel function and appearance. The parent should also learn how to care for the ostomy and change the bag until the second surgery.

A. Half-strength infant formula B. Half-strength orange juice C. Sterile water D. Oral electrolyte solution

Correct Answer is D

Explanation

Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.

Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.

Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.

Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a parent of a child who has Hirschsprung disease and is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

Correct Answer is D

Explanation

A nurse is monitoring an infant who is 6 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings are consistent with which of the following diagnoses?

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

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?

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings should indicate to the nurse that the treatment is effective?

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?