Nokea
What interventions will the nurse perform when feeding a child with pyloric stenosis?
- A. Give a formula thinned with water.
- B. Burp the infant before and during feeding.
- C. Give the feeding slowly.
- D. Refeed if the infant vomits.
- E. Position infant on left side after feeding.
Correct Answer: B,C,D
Rationale: Burping, slow feeding, and refeeding if vomiting occurs help manage pyloric stenosis; the infant is positioned on the right side, not left.
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What is the treatment of choice for a child with intussusception?
- A. A barium enema
- B. Immediate surgery
- C. IV fluids until the spasms subside
- D. Gastric lavage
Correct Answer: A
Rationale: A barium enema can often reduce intussusception by 'un-telescoping' the bowel, avoiding surgery.
What would be included in regard to potential side effects?
- A. Diarrhea
- B. Skin rash
- C. Red stool
- D. Metallic taste
Correct Answer: C
Rationale: Pyrvinium, used for pinworm treatment, commonly causes red stools and can stain clothing.
What description of a child's stool characteristic leads the nurse to suspect intussusception?
- A. Currant jelly
- B. Black and tarry
- C. Green liquid
- D. Greasy and foul-smelling
Correct Answer: A
Rationale: Currant jelly stools, consisting of blood and mucus, are indicative of intussusception due to intestinal obstruction.
Which assessment would the nurse report to the physician immediately?
- A. 2-month-old with a urine output of 150 mL in 24 hours
- B. 3-year-old with a urine output of 650 mL in 24 hours
- C. 8-year-old with a urine output of over 1000 mL in 24 hours
- D. 14-year-old with a urine output of 800 mL in 24 hours
Correct Answer: A
Rationale: A 2-month-old's urine output of 150 mL/24 hours is significantly below the expected 400-500 mL, indicating possible dehydration.
Which statement made by a parent alerts the nurse to the need for additional education about poison prevention?
- A. I keep the poison control center phone number easily accessible.'
- B. All medication is kept out of reach in a locked cabinet.'
- C. I keep a bottle of syrup of ipecac handy.'
- D. Our garden is free from marigolds.'
Correct Answer: C
Rationale: Keeping syrup of ipecac is outdated; the AAP recommends against it due to risks of uncontrolled vomiting.