The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. The infant vomited once this morning and had two episodes of diarrhea; the last episode contained mucus and a small amount of blood. The mother asks what she should do. Select the nurse's best response.

Correct Answer: D

Rationale: The correct response, D, instructs the mother to take the child to the emergency room immediately because the symptoms described (vomiting, bloody diarrhea, mucus) are indicative of intussusception, a serious condition where one part of the intestine slides into another part, causing a blockage. This is a medical emergency requiring prompt intervention to prevent complications like bowel perforation. Option A is incorrect because it lacks urgency in addressing the potentially life-threatening situation. Option B is also incorrect as waiting for another episode of vomiting before seeking medical attention can delay necessary treatment. Option C is incorrect as it assumes the symptoms are due to a formula allergy without considering the severity of the presentation. In an educational context, it's crucial for nurses to recognize red flag symptoms in pediatric patients that warrant immediate medical attention. Understanding the urgency of certain symptoms like bloody diarrhea in infants can help prevent delays in diagnosis and treatment of serious conditions like intussusception, ultimately improving patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) 13-year-old who has just started her menses. During menstruation, females may experience increased fluid loss due to blood loss, which can put them at risk for dehydration. Providing extra fluids during this time can help maintain hydration levels. Option A) 7-day-old receiving phototherapy typically needs strict fluid management due to the risk of fluid overload, making extra fluids not recommended in this case. Option B) A 6-month-old with newly diagnosed pyloric stenosis may experience vomiting, leading to fluid loss; however, the priority in this situation is to address the underlying condition and ensure adequate intake rather than just increasing fluids. Option C) A 2-year-old with pneumonia may also be at risk for dehydration due to fever and increased respiratory rate, but the focus of care would be on treating the pneumonia and ensuring adequate hydration rather than just providing extra fluids. Educationally, it is essential for pediatric healthcare providers to understand the specific needs of children in different clinical situations to provide individualized care. Understanding the factors that can contribute to dehydration in children, such as increased fluid loss during menstruation in adolescents, is crucial for effective nursing interventions to prevent complications related to dehydration.

Correct Answer: B

Rationale: Necrotizing enterocolitis (NEC) is a serious condition in infants characterized by inflammation and tissue death in the intestines. Bloody diarrhea is a key manifestation of NEC due to the damage and necrosis occurring in the intestinal lining, leading to blood in the stool. This is a critical indicator that the infant may be developing NEC and requires immediate medical attention. Option A, absorption of bolus orogastric feedings at a faster rate, is not indicative of NEC. NEC typically presents with feeding intolerance, abdominal distension, and other systemic signs rather than an increase in absorption rate. Increased bowel sounds (Option C) can be a nonspecific finding and may occur in various gastrointestinal conditions. It is not specific to NEC and does not provide a definitive indication of NEC development. An infant appearing hungry right before a scheduled feeding (Option D) is also a nonspecific finding and does not directly correlate with NEC. Hunger cues are common in infants and do not necessarily suggest NEC. In an educational context, understanding the specific manifestations of NEC is crucial for pediatric nurses to promptly identify and intervene in cases of NEC. Early recognition and appropriate management are essential in improving outcomes for infants with NEC. Nurses must be vigilant in assessing for signs like bloody diarrhea to ensure timely intervention and prevent complications associated with NEC.

Correct Answer: D

Rationale: In managing gastroesophageal reflux (GER) in a 2-month-old, the nurse should include holding the infant in an upright position for 30 minutes following a feeding (Option D) in the plan of care. This position helps prevent the reflux of stomach contents into the esophagus by utilizing gravity to aid digestion and reduce regurgitation. Option A is incorrect because placing the infant in an infant seat immediately after feedings can actually increase intra-abdominal pressure, worsening GER symptoms. Option B is also incorrect as placing the infant in the prone position after feeding increases the risk of aspiration. Option C is incorrect because while it is true that most infants outgrow GER by the first year of life, it is important to provide symptomatic relief and support to the infant and parents in the meantime. Educational context: Understanding the correct positioning after feeding is crucial in managing GER in infants and can significantly impact their comfort and reduce symptoms. Nurses play a key role in educating parents on appropriate interventions to alleviate GER symptoms and improve the overall well-being of the infant.

Correct Answer: D

Rationale: In abetalipoproteinemia, a rare genetic disorder affecting lipid metabolism, the correct answer is D) normal intellectual development. This is because abetalipoproteinemia primarily affects lipid transport, leading to very low plasma levels of cholesterol (option B) and triglycerides (option C). Acanthocytes (spur cells) are also commonly seen in the peripheral blood smear of individuals with abetalipoproteinemia (option A). The incorrect options (A, B, C) are manifestations commonly associated with abetalipoproteinemia due to the inability to properly transport lipids for absorption and metabolism. Acanthocytes result from alterations in lipid composition of the red blood cell membrane. Extremely low levels of cholesterol and triglycerides are characteristic features of this condition as these lipids are typically transported in lipoproteins that are deficient in individuals with abetalipoproteinemia. Educationally, understanding the pathophysiology and clinical manifestations of abetalipoproteinemia is crucial for pediatric gastrointestinal nursing interventions. It helps nurses recognize key signs and symptoms, provide appropriate care, and educate patients and families on dietary modifications and lipid supplementation to manage the condition effectively. The emphasis on intellectual development being normal in abetalipoproteinemia highlights the specific nature of the disorder's impact on lipid metabolism without affecting cognitive function.