Exhibits
The nurse is reviewing the assessment data.
Which are the 3 most likely reasons that the infant is crying?
Hunger
Opioid withdrawal
Hemorrhage
Separation anxiety
Pain
Hypovolemia
Hypoxia
Correct Answer : A,E,F
A. Hunger – The infant is NPO postoperatively but is accustomed to regular feedings. Hunger-related distress is common in infants after surgery, especially when oral intake is restricted. Since the infant has a history of GERD and fundoplication surgery, feedings are likely delayed to prevent complications, contributing to crying.
B. Opioid withdrawal – There is no indication that the infant has been on chronic opioid therapy before surgery. Opioid withdrawal symptoms typically occur in infants exposed to opioids for prolonged periods (e.g., neonatal abstinence syndrome), which is not relevant in this case.
C. Hemorrhage – The surgical dressing is clean and dry, meaning there are no visible signs of bleeding at the incision site. If significant internal bleeding were occurring, the infant would likely show signs of pallor, tachycardia, and hypotension, which are not present.
D. Separation anxiety – Separation anxiety typically develops around 6–9 months of age, when infants become more aware of their caregivers' presence. At 4 months, infants can recognize caregivers but do not yet exhibit true separation distress, making this an unlikely reason for crying.
E. Pain – Postoperative pain is a common cause of crying in infants after surgery. Signs of pain in nonverbal infants include crying, facial grimacing, irritability, and body tension. Since the infant has just undergone fundoplication surgery, pain is a likely contributing factor.
F. Hypovolemia – The infant is receiving IV fluids (Dextrose 5% with sodium chloride 0.45%), but fluid deficits can still occur postoperatively due to preoperative fasting, surgical fluid losses, or inadequate replacement. Hypovolemia can cause discomfort, irritability, tachycardia, and crying.
G. Hypoxia – The infant is described as pink and well-perfused with clear breath sounds, which rules out respiratory distress as a likely cause of crying. If hypoxia were present, signs such as cyanosis, increased work of breathing, or abnormal breath sounds would be expected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 1+ edema on her lower extremities: Mild edema in the lower extremities is a common finding in the third trimester due to increased blood volume and venous stasis. It is not necessarily a concerning finding unless accompanied by signs of preeclampsia, such as hypertension or proteinuria.
B. Fundal height of 30 cm: At 34 weeks of gestation, the fundal height is typically expected to be within 2 cm of the gestational age (32–36 cm). A measurement of 30 cm is below the expected range and may indicate intrauterine growth restriction (IUGR) or oligohydramnios. This finding requires further evaluation by the healthcare provider.
C. Weight gain of 2 pounds (0.91 kg): A weight gain of approximately 1–2 pounds (0.45–0.91 kg) per week in the third trimester is within the normal range for pregnancy and does not require immediate intervention.
D. Fetal heart rate of 110 beats/minute: The normal fetal heart rate ranges between 110–160 beats per minute. While 110 bpm is at the lower end of normal, it is still within an acceptable range and does not necessarily indicate fetal distress. However, continued monitoring may be warranted if there are additional concerns.
Correct Answer is C
Explanation
A. Arched back. An arched back can be seen in conditions such as gastroesophageal reflux disease (GERD) or neurological disorders but is not a hallmark feature of the condition described. The presence of an olive-like mass and hunger despite vomiting suggests a different diagnosis.
B. Coffee-ground emesis. Coffee-ground emesis indicates the presence of digested blood, often seen in gastrointestinal bleeding. This is not a typical finding in infants with the described symptoms, which are more consistent with pyloric stenosis.
C. Projectile vomiting. The combination of dehydration, extreme hunger, and a palpable olive-like mass in the right upper abdomen is classic for hypertrophic pyloric stenosis. This condition causes progressive gastric outlet obstruction, leading to non-bilious, projectile vomiting after feeds. Vomiting occurs because food cannot pass through the thickened pyloric sphincter.
D. Frequent pauses. Frequent pauses during feeding may be observed in conditions such as respiratory distress or neuromuscular disorders, but they are not characteristic of pyloric stenosis. Infants with pyloric stenosis often appear eager to feed but vomit forcefully due to gastric outlet obstruction.
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