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A nurse is preparing to administer vaccines to a 4-month-old infant. Which of the following vaccines should the nurse plan to administer?
- A. Influenza
- B. Rotavirus
- C. Measles, mumps, rubella (MMR)
- D. Varicella (VAR)
Correct Answer: B
Rationale: Influenza: The influenza vaccine is typically administered annually starting at 6 months of age. It helps protect against seasonal influenza viruses and is usually recommended during the fall or winter months. Rotavirus: The rotavirus vaccine is routinely administered to infants starting at 2 months of age, with additional doses given at 4 and 6 months of age. It helps prevent rotavirus infection, which can cause severe diarrhea and vomiting in infants and young children. Measles, mumps, rubella (MMR): The MMR vaccine is typically administered around 12-15 months of age, with a second dose given at 4-6 years of age. It helps protect against measles, mumps, and rubella, which are contagious viral infections that can cause serious complications. Varicella (VAR): The varicella vaccine, also known as the chickenpox vaccine, is usually administered around 12-15 months of age, with a second dose given at 4-6 years of age. It helps prevent chickenpox, a highly contagious viral infection characterized by a rash and fever.
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A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding?
- A. Left side
- B. Upright
- C. Right side
- D. Prone
Correct Answer: B
Rationale: Left side: Placing the infant on the left side after feeding is not typically recommended for managing gastroesophageal reflux. This position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Upright: This is the correct answer. Placing the infant in an upright position after feeding can help reduce gastroesophageal reflux. Gravity helps keep stomach contents down, preventing them from flowing back up into the esophagus. Holding the infant upright on the caregiver's shoulder or in a baby carrier can be effective in minimizing reflux symptoms. Right side: Placing the infant on the right side after feeding is not typically recommended for managing gastroesophageal reflux. Similar to the left side, this position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Prone: Placing the infant in a prone (face-down) position after feeding is not recommended due to the risk of sudden infant death syndrome (SIDS). Prone positioning is associated with an increased risk of SIDS, and current guidelines advise against placing infants to sleep or rest on their stomachs. Additionally, a prone position may not effectively reduce gastroesophageal reflux and may pose other risks to the infant's health and safety.
A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will have to feed my baby formula, rather than breast milk.
- B. I should move my baby into a side-lying position during sleep.
- C. My baby's formula can be thickened with oatmeal.
- D. I will keep my baby in an upright position after feedings.
Correct Answer: D
Rationale: I will have to feed my baby formula, rather than breast milk.' - This statement indicates a misunderstanding. Breast milk is generally preferred for infants with gastroesophageal reflux (GER) because it is more easily digested and less likely to exacerbate reflux symptoms compared to formula. Breastfeeding mothers may be encouraged to continue breastfeeding, and formula-fed infants may benefit from specialized formulas designed to reduce reflux symptoms. 'I should move my baby into a side-lying position during sleep.' - This statement indicates a misunderstanding. Placing an infant in a side-lying position during sleep is not recommended due to the risk of sudden infant death syndrome (SIDS). Instead, infants with GER should be placed on their back to sleep, as recommended by safe sleep guidelines. Elevating the head of the crib or bassinet slightly may also help reduce reflux symptoms during sleep. 'My baby's formula can be thickened with oatmeal.' - This statement indicates an understanding of the teaching. Thickening formula with oatmeal or rice cereal can help reduce gastroesophageal reflux (GER) symptoms in infants by making the formula heavier and less likely to reflux back into the esophagus. However, this should only be done under the guidance of a healthcare provider to ensure proper preparation and feeding technique. 'I will keep my baby in an upright position after feedings.' - This statement indicates an understanding of the teaching. Keeping the baby in an upright position after feedings can help reduce reflux symptoms by allowing gravity to keep the stomach contents down. Parents can hold the baby upright on their shoulder or in an infant seat for a period of time after feeding to minimize reflux episodes.
A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)
- A. Wheezing
- B. Rigid abdomen
- C. Pallor
- D. Weight loss
- E. Vomiting
Correct Answer: A,D,E
Rationale: A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract. B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants. C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER. D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively. E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.
A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
- A. Projectile vomiting
- B. Metabolic acidosis
- C. Effortless regurgitation
- D. Distended abdomen
Correct Answer: A
Rationale: Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents. Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly. Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents. A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.
A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?
- A. Increase in appetite
- B. Tugging on the affected ear lobe
- C. Erythema and edema of the affected auricle
- D. Bluish-green discharge from the ear canal
Correct Answer: B
Rationale: Increase in appetite: Otitis media, an infection or inflammation of the middle ear, typically causes discomfort and pain in infants. As a result, they may experience a decrease in appetite rather than an increase. Tugging on the affected ear lobe: Tugging or pulling on the affected ear lobe is a common sign of ear pain in infants with otitis media. It occurs because the pain from the middle ear extends to the outer ear canal. Erythema and edema of the affected auricle: Otitis media primarily affects the middle ear, so erythema (redness) and edema (swelling) are not typically observed on the outer ear (auricle). Instead, these symptoms are more commonly seen in external ear infections, such as otitis externa. Bluish-green discharge from the ear canal: Bluish-green discharge from the ear canal is not a typical finding in otitis media. It may suggest a secondary bacterial infection or another underlying condition, but it is not a characteristic feature of otitis media.