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?
"Bring your baby into the clinic today."
"Give your infant an oral rehydration solution."
"Burp your baby more frequently during feedings."
"Try switching to a different formula."
The Correct Answer is A
Choice A: This response is appropriate, as it indicates urgency and concern for the infant's condition. Projectile vomiting immediately after eating can be a sign of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Pyloric stenosis can prevent food from passing through and cause dehydration, electrolyte imbalance, or weight loss. The infant needs to be evaluated by a provider as soon as possible and may need surgery to correct the problem.
Choice B: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Oral rehydration solution can help replace fluids and electrolytes lost through vomiting, but it does not treat pyloric stenosis or prevent further vomiting. Oral rehydration solution may also be vomited out by the infant if given too soon or too much.
Choice C: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Burping the baby more frequently during feedings can help release air bubbles and prevent gas or colic, but it does not treat pyloric stenosis or prevent further vomiting. Burping may also trigger vomiting by increasing pressure on the stomach.
Choice D: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Switching to a different formula can help if the infant has an allergy or intolerance to certain ingredients in their current formula, but it does not treat pyloric stenosis or prevent further vomiting. Switching formulas may also cause diarrhea or constipation by changing the infant's bowel flora.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Applying heat to a bleeding site can increase blood flow and worsen the bleeding. This statement indicates a need for further teaching, as the parent should avoid applying heat and use cold compresses instead.
Choice B: Having the child rest can reduce physical activity and prevent further injury or bleeding. This statement indicates that the parent understands the teaching, as resting is one of the recommended actions for controlling a minor bleeding episode.
Choice C: Compressing the site can apply pressure and stop the bleeding. This statement indicates that the parent understands the teaching, as compressing is one of the recommended actions for controlling a minor bleeding episode.
Choice D: Elevating the affected part can reduce blood pressure and slow down the bleeding. This statement indicates that the parent understands the teaching, as elevating is one of the recommended actions for controlling a minor bleeding episode.
Correct Answer is A
Explanation
Choice A: A 13% weight loss is a sign of severe dehydration in an infant, as it indicates a significant loss of body fluids and electrolytes. Dehydration can occur in an infant who has acute gastroenteritis, which is a condition that causes inflammation of the stomach and intestines, leading to vomiting and diarrhea. A 13% weight loss can also cause other signs of dehydration, such as sunken eyes, dry mouth, decreased urine output, and lethargy.
Choice B: A bulging anterior fontanel is not a sign of dehydration in an infant, but rather a sign of increased intracranial pressure, which can be caused by various conditions, such as meningitis, encephalitis, or head trauma. A bulging anterior fontanel can also cause other signs of increased intracranial pressure, such as irritability, headache, vomiting, or seizures.
Choice C: A capillary refill of 3 seconds is not a sign of dehydration in an infant, but rather a sign of normal perfusion and circulation. Capillary refill is the time it takes for the color to return to the nail bed after applying pressure. A normal capillary refill is less than 2 seconds. A prolonged capillary refill of more than 2 seconds can indicate poor perfusion and circulation, which can be caused by various conditions, such as shock, hypothermia, or heart failure.
Choice D: Bradypnea is not a sign of dehydration in an infant, but rather a sign of decreased respiratory rate, which can be caused by various conditions, such as hypoxia, narcotic overdose, or brain injury. Bradypnea can also cause other signs of respiratory distress, such as cyanosis, confusion, or loss of consciousness.
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