The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucous and a small amount of blood, stating "her stool kind of looks like currant jelly". She asks the nurse what she should do. Select the nurse's best response.
Many infants display these symptoms when they develop an allergy to their formula. Try switching to a soy based formula.
Try feeding the infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency department for some tests and intravenous rehydration.
Do not worry about the blood and mucous in the stool: it is not unusual for infants to have blood in their stools because their intestines are more sensitive.
Your infant will need to have some tests in the emergency room to determine if anything serious is going on.
The Correct Answer is D
Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.
Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.
Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.
Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Aspirin is a part of the treatment for children with Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels. Aspirin is given to reduce fever, inflammation, and the risk of developing coronary artery aneurysms. Aspirin is usually given in high doses during the acute phase of the disease and then in low doses as a preventive measure until the inflammation subsides.
Choice B reason: This is not a good choice. Aspirin is not contraindicated for children with Kawasaki disease, unlike other conditions such as Reye syndrome or viral infections. Aspirin is a beneficial and essential part of the treatment for children with Kawasaki disease, as it can prevent serious and potentially fatal complications.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as weight alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use weight in conjunction with other measures, such as height, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice B reason: This statement is incorrect, as height alone is not a reliable indicator of overweight or obesity in children and adolescents, as it does not account for the variations in growth, age, sex, and body composition. The nurse should use height in conjunction with other measures, such as weight, BMI, and growth charts, to assess the nutritional status and health risks of the child.
Choice C reason: This statement is incorrect, as body surface area (BSA) is not a recommended method of screening for overweight or obesity in children and adolescents, as it is not widely used or validated in this population. BSA is a measure of the total area of the skin, which can be calculated using various formulas based on weight and height. BSA is mainly used for dosing certain medications, such as chemotherapy, and for estimating the metabolic rate.
Choice D reason: This statement is correct, as body mass index (BMI) is the recommended method of screening for overweight or obesity in children and adolescents, as it is a simple and standardized measure of body fatness that can be used for comparison across different populations and age groups. BMI is calculated by dividing the weight in kilograms by the height in meters squared. The nurse should use the BMI-for-age percentile charts to interpret the BMI value and classify the child as underweight, healthy weight, overweight, or obese
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