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 B
Explanation
Choice A reason: This statement is incorrect, as letting the child feed herself finger foods is not a risk factor for aspiration, but a way to promote self-feeding skills, independence, and appetite. The nurse should encourage the parents to offer the child a variety of soft, bite-sized, and nutritious foods, such as cooked vegetables, fruits, cheese, or bread, and to supervise the child during meals.
Choice B reason: This statement is correct, as giving whole milk is recommended for children between 1 and 2 years old, as it provides adequate fat, protein, calcium, and vitamin D for their growth and development. The nurse should advise the parents to give the child about 16 to 24 ounces of whole milk per day, and to avoid low-fat or skim milk until the child is 2 years old.
Choice C reason: This statement is incorrect, as delaying the introduction of foods which may cause allergies is not necessary or beneficial for the prevention of food allergies in children. The nurse should inform the parents that there is no evidence that avoiding certain foods, such as eggs, peanuts, or fish, can reduce the risk of food allergies, and that introducing these foods early, around 6 months of age, may actually prevent or reduce the severity of food allergies.
Choice D reason: This statement is incorrect, as transitioning to 1% milk is not advisable for children under 2 years old, as it does not provide enough fat and calories for their growth and development. The nurse should explain to the parents that low-fat or skim milk is not suitable for young children, as they need more fat for their brain and nervous system development, and that switching to 1% milk should only be done after consulting with the doctor.
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