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 statement is correct, as standard precautions are the minimum level of infection control practices that should be applied to all patients, regardless of their diagnosis or presumed infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe handling of sharps and contaminated items, and environmental cleaning. Standard precautions are sufficient for most patients with HIV, unless they have other infections that require additional precautions.
Choice B reason: This statement is incorrect, as droplet precautions are not required for patients with HIV, unless they have other infections that are transmitted by respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorting with other patients with the same infection, and limiting the movement of the patient outside the room.
Choice C reason: This statement is incorrect, as contact precautions are not required for patients with HIV, unless they have other infections that are transmitted by direct or indirect contact, such as Clostridioides difficile, scabies, or herpes simplex virus. Contact precautions include wearing gloves and gowns when entering the patient's room, placing the patient in a private room or cohorting with other patients with the same infection, and dedicating patient-care equipment to the patient or disinfecting it before use on another patient.
Choice D reason: This statement is incorrect, as airborne precautions are not required for patients with HIV, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Correct Answer is D
Explanation
Choice A reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause is unknown, but it may be related to genetic, environmental, or hormonal factors.
Choice B reason: Slow feeding will not be sufficient to manage hypertrophic pyloric stenosis. The infant will have persistent vomiting, dehydration, and weight loss due to the obstruction of the pylorus.
Choice C reason: Dietary restrictions will not be effective for hypertrophic pyloric stenosis. The infant will not be able to tolerate any oral intake until the pylorus is surgically corrected.
Choice D reason: Surgery will be necessary to treat hypertrophic pyloric stenosis. The surgery is called pyloromyotomy, which involves cutting the thickened muscle of the pylorus to allow the stomach to empty into the duodenum.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.