The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Perform guided imagery.
Have one of the parents hold the baby.
Encourage the baby's mother to breastfeed the baby.
Request a prescription for an anti-inflammatory drug.
Correct Answer : B,C
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.
Choice B rationale
Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.
Choice C rationale
Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.
Choice D rationale
Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.
Choice B rationale
While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.
Choice C rationale
Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.
Choice D rationale
Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.
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