The nurse has reviewed the Nurses' Notes 1 month later.
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.
What notable improvement or change has been observed in the infant's condition during the one-month follow-up visit?
Sleeping pattern.
Irritability.
Weight.
Regurgitation.
Heart rate.
The Correct Answer is B
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 initial notes, indicating the infant's discomfort. However, in the follow-up visit, there is no mention of irritability, suggesting an improvement in this symptom. Monitoring irritability is essential to assess the effectiveness of interventions for gastroesophageal reflux.
Choice C rationale:
Weight is mentioned in both the initial and follow-up notes. While monitoring weight is essential, there is no indication of weight loss or inadequate weight gain in the follow-up, suggesting that the infant's nutritional status is stable.
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 B
Explanation
The correct answer is choiceb. “We will place the diaper under the straps.”
Choice A rationale:
Adjusting the straps daily is not recommended.The straps should only be adjusted by a healthcare professional to ensure proper fit and effectiveness.
Choice B rationale:
Placing the diaper under the straps is correct.This helps to keep the harness clean and dry, and ensures that the straps remain in the correct position.
Choice C rationale:
The duration of wearing the Pavlik harness is typically longer than 2 weeks.It is usually worn for about 6-12 weeks, depending on the doctor’s recommendation.
Choice D rationale:
Applying lotion to the skin under the straps is not advised as it can cause skin irritation and affect the fit of the harness.
Correct Answer is A
Explanation
Choice A rationale:
Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.
Choice C rationale:
Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.
Choice D rationale:
Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.
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