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 D
Explanation
Choice A: A video game is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A video game may provide distraction or entertainment, but it does not help the child cope with or understand their condition.
Choice B: A period of play in the playroom is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it does not address the child's feelings or concerns about the injection. A period of play in the playroom may provide socialization or stimulation, but it does not help the child cope with or understand their condition.
Choice C: A storybook about a 4-year-old child is not a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection unless the storybook is specifically about diabetes mellitus and insulin injections. A storybook about a 4-year-old child may provide identification or imagination, but it does not help the child cope with or understand their condition.
Choice D: A needleless syringe and a doll is a therapeutic play activity for a 4-year-old child who is distressed after an insulin injection, as it allows the child to express their feelings and concerns about the injection through role-playing and simulation. A needleless syringe and a doll can help the child cope with and understand their condition by providing mastery, control, and education.
Correct Answer is D
Explanation
Choice A: Placing the child on a no-salt-added diet is an important intervention for acute glomerulonephritis, as salt can increase fluid retention and blood pressure. However, this is not the priority action, as it does not address the immediate problem of fluid overload.
Choice B: Maintaining a saline lock is a useful measure for acute glomerulonephritis, as it allows for easy access to administer fluids or medications if needed. However, this is not the priority action, as it does not monitor the fluid status of the child.
Choice C: Educating the parents about potential complications is an essential part of nursing care for acute glomerulonephritis, as it can help them recognize signs of worsening conditions and seek timely medical attention. However, this is not the priority action, as it does not assess the current condition of the child.
Choice D: Checking the child's daily weight is the priority action for acute glomerulonephritis, as it is the most accurate indicator of fluid balance and kidney function. A sudden increase in weight can indicate fluid retention and edema, which can lead to heart failure or pulmonary edema. A decrease in weight can indicate dehydration or diuresis, which can lead to hypovolemia or electrolyte imbalance.
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