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 C
Explanation
When caring for a school-age child immediately following a tonsillectomy in the Post-Anesthesia Care Unit (PACU), the nurse should prioritize actions that promote the child's comfort and recovery while minimizing the risk of complications. The most appropriate action is:
c) Offer the child ice cream when alert.
After a tonsillectomy, cold and soothing foods like ice cream can help alleviate throat pain and reduce swelling. However, it's crucial to wait until the child is fully alert and able to swallow safely. Ice cream provides a cool and gentle way to soothe the surgical site.
The other options may not be suitable immediately following a tonsillectomy:
a) Placing the child in a side-lying position: While positioning can be essential for airway management, it's not a specific intervention related to a tonsillectomy in the immediate postoperative period.
b) Instructing the child to drink fluids through a straw: Drinking through a straw may increase the risk of bleeding, which is a concern after a tonsillectomy. It's often recommended to avoid straws initially.
d) Encouraging the child to deep breathe and cough: While respiratory care is generally important, the immediate focus after a tonsillectomy is on maintaining a clear airway and managing pain. Deep breathing and coughing exercises may be introduced later in the recovery process.
It's important for the nurse to follow the specific postoperative guidelines provided by the surgical team and be attentive to the child's individual needs and responses.
Correct Answer is A
Explanation
Answer is A. Use a 24-gauge catheter to start the IV.
A 24-gauge catheter is the smallest and most appropriate size for an infant's vein¹. It reduces the risk of infiltration, phlebitis, and thrombosis².
B. Start the IV in the infant's foot. Statement is wrong because starting the IV in the foot can interfere with the infant's mobility and increase the risk of infection³. The preferred sites for IV insertion in infants are the scalp, hand, or arm veins⁴.
C. Change the IV site every 3 days. Statement is wrong because changing the IV site every 3 days is not recommended for infants and children. The IV site should be changed only when clinically indicated, such as signs of infection, infiltration, or phlebitis.
D. Cover the insertion site with an opaque dressing. Statement is wrong because covering the insertion site with an opaque dressing can obscure the visibility of the site and prevent early detection of complications. A transparent dressing is preferred as it allows for continuous assessment of the site.
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