Exhibit 1. Nurses' Notes.
Today, 1000: Exhibit 2. Infant here at the provider's office for a scheduled visit.
The infant is in their parent's arms, grimacing.
S1 and S2 auscultated, no murmur noted.
Respirations are symmetric and unlabored with abdominal movement.
Abdomen is soft and flat, bowel sounds present.
Current weight is 4.1 kg (9 lb) The parent states they have exclusively breast- and bottle-fed breastmilk to the infant since birth.
The parent states the infant sometimes chokes with bottle feedings.
The parent noticed that the infant recently started "spitting up" during the night and after feeds, and cries excessively.
They state the infant has been vomiting more forcefully and has become disinterested in feeding.
Today, 1010: Exhibit 3. Provider assessed infant and discussed gastroesophageal reflux with parent.
Education provided.
1 month later: Infant here for follow-up visit.
Infant is calm and alert in parent's arms.
Parent states infant is sleeping through the night.
Parent states infant continues to spit up. States they have been thickening bottle feedings and the infant has taken them well.
Current weight is 5 kg (11 lb)
What is the most notable change observed in the infant's condition during the one-month follow-up visit?
Sleeping pattern.
Irritability.
Weight.
Regurgitation.
Heart rate.
Bottle feeding.
Correct Answer : C,D,F
Choice A rationale:
The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.
Choice B rationale:
Irritability is mentioned in the notes, but it is not a parameter that directly reflects the improvement or worsening of the infant's condition. While irritability can be a symptom of discomfort due to reflux, it's not a parameter to monitor progress over time.
Choice C rationale:
Monitoring the infant's weight is crucial in this scenario. Weight gain is a significant indicator of the infant's overall health and nutritional status. A decrease in weight gain could indicate feeding difficulties or other health issues. In this case, the weight has increased, suggesting improvement in the infant's condition.
Choice D rationale:
Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.
Choice E rationale:
Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.
Choice F rationale:
Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Weighing the child once each month is not the most relevant information to include in teaching parents of a preschool-age child with heart failure. Monitoring weight is important, but it should be done more frequently, preferably daily, to track any sudden weight gain, which could indicate fluid retention and worsening heart failure.
Choice B rationale:
Withholding digoxin if the child's pulse is greater than 100/min is not appropriate. Digoxin is commonly prescribed for heart failure in pediatric patients to strengthen the heartbeat. Instead, the nurse should teach the parents to monitor the child's pulse rate regularly and report any significant changes to the healthcare provider.
Choice C rationale:
Increasing the child's oxygen flow rate until the child no longer has cyanosis is incorrect. While oxygen therapy might be necessary for a child with heart failure, adjusting the oxygen flow rate based on cyanosis is not the appropriate approach. Oxygen therapy should be prescribed and monitored by healthcare providers based on the child's oxygen saturation levels.
Choice D rationale:
Providing for periods of rest is the correct choice. Children with heart failure often tire easily due to the heart's reduced ability to pump blood effectively. Allowing the child to rest helps conserve energy and prevents additional strain on the heart. This instruction promotes the overall well-being and comfort of the child, aligning with the management of heart failure.
Correct Answer is A
Explanation
Choice A rationale:
A sausage-shaped abdominal mass is a classic sign of intussusception, a condition where one segment of the intestine telescopes into another, causing obstruction. This is a medical emergency that requires prompt intervention.
Choice B rationale:
Increased urinary output is not a characteristic finding of intussusception. Instead, the child may present with signs of dehydration due to vomiting, diarrhea, and decreased oral intake caused by the obstruction.
Choice C rationale:
Constipation is a symptom that can be associated with various gastrointestinal disorders but is not specific to intussusception. In intussusception, the child typically experiences severe abdominal pain, vomiting, and the classic sausage-shaped abdominal mass.
Choice D rationale:
A board-like abdomen can occur in conditions such as peritonitis, but it is not a typical finding in intussusception. The presence of a sausage-shaped abdominal mass is the hallmark sign of intussusception.
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