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?

“Bring your infant into the clinic today to be seen.”.

“Burp your child more frequently during feedings.”.

“Give your infant an oral rehydrating solution.”.

“You might want to try switching to a different formula.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention.
Choice B rationale
While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described.
Choice C rationale
While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution.
Choice D rationale
Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.

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Correct Answer is A

Explanation

The correct answer is A. Potential Condition.

The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.

A. Assess fluid balance. B. Maintain fluid therapy. C. Rehydrate. D. Introduce a regular diet.

Correct Answer is A

Explanation

Choice A rationale
Assessing fluid balance is the priority action when caring for a child with severe diarrhea. Diarrhea can lead to significant fluid and electrolyte loss, which can result in dehydration. Early recognition and treatment of dehydration are crucial to prevent further complications.
Choice B rationale
While maintaining fluid therapy is an important part of managing severe diarrhea, the first step should be to assess the child’s fluid balance.
Choice C rationale
Rehydration is a key part of the treatment for severe diarrhea, but it should be done after assessing the child’s fluid balance.
Choice D rationale
Introducing a regular diet is usually done after the acute phase of diarrhea has resolved and the child’s fluid balance has been restored.

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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?

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Correct Answer is A

Explanation

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

Correct Answer is A

Explanation

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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?