Exhibits

The nurse is reviewing the prescription and planning the appropriate pain management.

Complete the following sentence by choosing from the lists of options.

For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.

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.

A. Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B. Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C. Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D. Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E. Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F. Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G. Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.