A one-month old baby has been admitted to the pediatric unit with the diagnosis of pyloric stenosis. Which of the following assessments is the highest priority for the nurse to report to the baby's primary health-care provider?

Undigested emesis

Apical heart rate of 156 bpm

Serum potassium of 3.6 mEq/dL

Sunken fontanelle

Answer and Explanation

The Correct Answer is D

A.   Undigested emesis is common in pyloric stenosis and is not the most urgent finding.
B.   An apical heart rate of 156 bpm is elevated, but it is not the most urgent concern compared to dehydration and electrolyte imbalances.
C.   A serum potassium of 3.6 mEq/L is within normal limits, so this is not the most pressing concern for the baby at this time.
D.   A sunken fontanelle is a sign of dehydration, which is a significant and urgent concern in pyloric stenosis. Dehydration can lead to severe complications, so this requires immediate attention.

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Correct Answer is D

Explanation

A. Addison’s disease is characterized by adrenal insufficiency, not fluid volume excess. Monitoring for fluid volume deficit is more appropriate.
B. Hyperglycemia is not a typical manifestation of Addison's disease, as the condition is associated with a deficiency of cortisol, which can result in low blood glucose levels.
C. A low-sodium diet is not indicated for Addison's disease; in fact, the child may require increased sodium intake due to adrenal insufficiency.
D. Cortisol replacement therapy is a cornerstone of managing Addison’s disease. It helps to compensate for the deficient cortisol, which is necessary for normal metabolism and stress response.

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

Correct Answer is C

Explanation

A. Half-strength infant formula is not a clear liquid and could be too complex for an infant recovering from surgery.
B. Sterile water does not provide electrolytes, which are important for recovery from surgery and preventing dehydration.
C. Oral electrolyte solution is ideal for an infant post-surgery because it helps replace lost fluids and electrolytes.
D. Half-strength orange juice is not appropriate post-surgery because the acidity can irritate the stomach and intestines, delaying recovery.

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A one-month old baby has been admitted to the pediatric unit with the diagnosis of pyloric stenosis. Which of the following assessments is the highest priority for the nurse to report to the baby's primary health-care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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