An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Gather supplies for an Intravenous (IV) infusion.

Measure abdominal circumference.

Prepare for anorectal manometry.

Monitor strict urinary output

Answer and Explanation

The Correct Answer is B

A. Gathering supplies for an Intravenous (IV) infusion may be necessary if the infant becomes dehydrated or requires fluid resuscitation, but it is not the first action to take when there are concerns about a potential intestinal obstruction.

B. Measure abdominal circumference.

The infant's failure to pass meconium stool and the vomiting of bilious secretions are concerning signs that could indicate an obstruction in the gastrointestinal tract. Measuring the abdominal circumference is an essential initial assessment to determine if there is abdominal distension or enlargement, which can be a sign of an obstruction. Abdominal distention can help the healthcare provider assess the severity of the issue and make informed decisions regarding further diagnostic tests and interventions.

C. Preparing for anorectal manometry is not the first step in this situation. Anorectal manometry is a diagnostic test that may be considered later, depending on the findings and the healthcare provider's assessment.

D. Monitoring strict urinary output is not the primary concern in this case; the focus should be on assessing the infant's gastrointestinal status and potential bowel obstruction.

The nurse should promptly measure the infant's abdominal circumference to assess for signs of abdominal distension or obstruction and then communicate these findings to the healthcare provider for further evaluation and intervention.

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Correct Answer is D

Explanation

A. Understanding the quality control process used to troubleshoot the pump is important, but it is a secondary assessment and educational component. The primary focus should be on the child's ability to operate the pump effectively.

B. Interpretation of fingerstick glucose levels is important for diabetes management, but it does not specifically address the use of an insulin pump.

C. Knowledge of glycosylated hemoglobin A1c levels is valuable for assessing long-term glycemic control but is not the primary assessment needed when considering the transition to an insulin pump.

D Ability to program the pump for basal insulin with mealtime boluses.

When a child with type 1 diabetes mellitus expresses an interest in using an insulin pump, the most important assessment is their ability to program and manage the pump effectively. The nurse should assess whether the child and their family have the knowledge and skills to use the pump, including setting basal insulin rates and delivering mealtime boluses. The successful use of an insulin pump requires a good understanding of its operation and the ability to make adjustments based on the child's specific needs and glucose levels.

The ability to manage the insulin pump effectively is essential to ensure safe and appropriate diabetes management, making it the most important assessment in this context.

A. Ibuprofen should be used prophylactically to prevent febrile seizures. B. Reassure the parents that febrile seizures decrease as the child grows older. C. Avoid excessive visual stimuli because it can precipitate seizure activity. D. Provide the child with a sponge bath for temperatures over 100.6° F (38.1° C)

Correct Answer is B

Explanation

A. Using ibuprofen prophylactically to prevent febrile seizures is not a standard approach and is not generally recommended. The focus should be on managing the child's fever with appropriate fever-reducing medications rather than attempting to prevent febrile seizures with medication.

B. Reassure the parents that febrile seizures decrease as the child grows older.

Febrile seizures are relatively common in young children and are typically associated with rapid increases in body temperature, often due to infections.

The most important information to convey to the parents is that febrile seizures are usually a benign and self-limited condition, and they tend to decrease in frequency and may even resolve as the child grows older. Reassuring parents about the natural course of febrile seizures is vital to alleviate their concerns. However, it's essential to educate them on fever management and when to seek medical attention for their child's febrile seizures.

C. Avoiding excessive visual stimuli is not a standard recommendation for preventing febrile seizures. Febrile seizures are primarily related to fever and not visual stimuli.

D. Providing a sponge bath for temperatures over 100.6° F (38.1° C) can help reduce fever, but it is not directly related to preventing febrile seizures. The main goal in such situations is to manage the fever itself.

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An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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