Nokea
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
- A. Arched back.
- B. Coffee-ground emesis.
- C. Projectile vomiting.
- D. Frequent pauses.
Correct Answer: C
Rationale: Projectile vomiting is characteristic of pyloric stenosis, indicated by the olive-like mass, hunger, and dehydration.
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History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which pain scales would be appropriate for this client? Select all that apply.
- A. FLACC Postoperative Pain Scale
- B. Riley Infant Pain Scale
- C. Poker Chip Tool
- D. Visual Analog Scale
- E. Numeric
- F. FACES
Correct Answer: A,B
Rationale: FLACC and Riley Infant Pain Scales assess behavioral cues in nonverbal infants, suitable for a 4-month-old post-surgery. Other scales require cognitive abilities beyond this age.
The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for client with preterm labor. The IV bag contains 'Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.' How many mL/hour should the nurse set the infusion pump?
- A. 450 mL/hour
Correct Answer: A
Rationale: For 6 grams in 20 minutes, 150 mL (6 ÷ 0.04 g/mL) is needed. Infusion rate is 150 mL ÷ 20 min × 60 = 450 mL/hour.
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which are the 3 most likely reasons that the infant is crying?
- A. Hunger
- B. Opioid withdrawal
- C. Hemorrhage
- D. Separation anxiety
- E. Pain
- F. Hypovolemia
- G. Hypoxia
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
- A. 3.3 mL
- B. 1.9 mL
- C. 5.0 mL
- D. 0.8 mL
Correct Answer: A
Rationale: For a 7 kg infant, 15 mg/kg = 105 mg. At 160 mg/5 mL, 105 mg requires 3.3 mL, providing effective pain relief without toxicity.