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What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
- A. Projectile vomiting.
- B. Effortless regurgitation.
- C. Metabolic acidosis.
- D. Distended abdomen.
Correct Answer: A
Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
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A child weighs 6 lbs and is to receive Ampicillin 50 mg/kg/24 hrs and then it's divided into q hr doses. How many mg will he receive with each dose?
- A. 90 mg
- B. 60 mg
- C. 36 mg
- D. 290 mg
Correct Answer: C
Rationale: Step 1: Convert the child's weight from lbs to kg. Since 1 lb is approximately 0.45 kg, a child who weighs 6 lbs weighs approximately 2.72 kg (6 lbs × 0.45 =2.72 kg). Step 2: Calculate the total daily dose of Ampicillin. The total daily dose is 50 mg/kg/day, so for a child who weighs 2.72 kg, the total daily dose would be approximately 136 mg (50 mg/kg/day × 2.72 kg = 136 mg/day). Step 3: Since the total daily dose is divided into q hr doses (4 doses per day), each dose would be approximately 34 mg (136 mg/day ÷ 4 doses/day = 34 mg/dose). So, the child will receive approximately 34 mg of Ampicillin with each dose.
A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034.
- B. Bounding pulse.
- C. BP 46/94 mm Hg.
- D. Distended neck veins.
Correct Answer: A
Rationale: A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration. A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse. A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure. Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
A nurse is assisting with collecting data from a 10-month-old in the emergency department. Medical History: Guardians brought the infant to the emergency room after witnessing the infant's arms and legs shaking. The infant did not respond to the guardians' voices during that time. The episode lasted approximately 5 min and the infant was sleeping soundly afterwards. On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation. The infant has no prior medical or surgical history. Born full-term at 40 weeks to a birth mother who had regular prenatal visits. Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Potential Condition
- B. Parameters to Monitor 1
- C. Parameters to Monitor 2
- D. Vitamin
- E. Blood pressure
Correct Answer: A
Rationale: The infant's symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant's neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- B. Collect a stool sample from the toddler.
- C. Determine if the toddler is voiding.
- D. Request evaluation of the toddler's serum electrolytes.
Correct Answer: C
Rationale: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child's hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children. Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child's hydration status needs to be assessed. Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child's hydration status, which is critical in managing acute gastroenteritis. Request evaluation of the toddler's serum electrolytes Requesting an evaluation of the toddler's serum electrolytes is also important, but it's typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child's hydration status.
A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?
- A. Haemophilus influenza type b (Hib)
- B. Inactivated poliovirus (IPv)
- C. Hepatitis B (HepB)
- D. Influenza
Correct Answer: D
Rationale: The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years. The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease. The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver. The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin.