Nokea
A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?
- A. Irregular palpable pulse
- B. Hyperactive bowel sounds
- C. Underweight for age
- D. Crying without tears
Correct Answer: D
Rationale: In this scenario, the infant presenting with vomiting, lethargy, and projectile vomiting indicates a potential serious condition. Crying without tears is a sign of dehydration, a critical condition that can lead to life-threatening complications in infants. Dehydration can rapidly worsen an infant's condition, making prompt intervention crucial to prevent further complications.
You may also like to solve these questions
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct Answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.
What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and take deep breaths.
- C. Report the findings to the healthcare provider.
- D. Identify the triggers that precipitated this attack.
Correct Answer: A
Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child.
The caregiver is caring for a 10-year-old child with a history of frequent ear infections. The parents are concerned about their child's hearing and speech development. What is the caregiver's best response?
- A. Let's schedule a hearing test and refer to a speech therapist if needed
- B. Most children outgrow ear infections and speech delays
- C. There is no need to worry unless the infections persist into adolescence
- D. Your child's hearing and speech should be normal by now
Correct Answer: A
Rationale: The appropriate response for the caregiver is to address the parents' concerns by suggesting scheduling a hearing test and potentially referring the child to a speech therapist if necessary. This proactive approach can help evaluate and support the child's hearing and speech development effectively.
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
The practical nurse is reinforcing education with the parents of a child prescribed iron supplements for iron-deficiency anemia. Which statement by the parents indicates they need further instruction?
- A. We will give the iron supplement with milk to reduce stomach upset.
- B. We should give the iron supplement with orange juice to improve absorption.
- C. The supplement may cause the stools to appear dark or black.
- D. We should store the iron supplements out of reach of children.
Correct Answer: A
Rationale: Iron supplements should not be given with milk as calcium can interfere with iron absorption. Instead, it is recommended to give it with a source of vitamin C, such as orange juice, to enhance iron absorption. Giving iron supplements with milk may decrease the absorption of iron and should be avoided in this case.