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 D
Explanation
Choice A reason: An axillary temperature of 37.3° C is within the normal range for a 10 month old child and does not indicate a complication of intussusception or its treatment.
Choice B reason: Mild abdominal pain is expected after an emergency reduction for intussusception and can be managed with analgesics and comfort measures.
Choice C reason: A BP of 100/54 is normal for a 10 month old child and does not reflect hypovolemia or shock, which are possible complications of intussusception.
Choice D reason: Currant jelly stools are a sign of intestinal bleeding and ischemia, which are serious complications of intussusception that require immediate medical attention. Currant jelly stools are red, mucus-like, and mixed with blood. They indicate that the intussusception has not been resolved or has recurred.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.
Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.
Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.
Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.
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