ATI RN
ATI Nur223g Pediatrics Sect 2 Final Exam Questions
Extract:
An infant whose guardian reports intermittent vomiting for several days. Guardian reports infant has been forcefully vomiting after feedings. Infant is very fussy and rooting and sucks vigorously on a pacifier. Axillary temperature: 38.2° C (100.8° F), Heart rate: 152/min, Respiratory rate: 30/min. Mucus membranes are dry. Anterior fontanel depressed and soft. Small amount of urine noted in the diaper, dark in color. Upper portion of the abdomen is distended. Palpable olive-shaped mass noted in the right mid-abdominal region. Ultrasound shows a mass that encircles the pyloric canal consistent with hypertrophic pyloric stenosis.
Question 1 of 5
A nurse is caring for an infant whose guardian reports intermittent vomiting for several days. Which of the following actions should the nurse take? (Select all that apply)
Correct Answer: B,C,D
Rationale:
Correct
Answer: B, C, D
Rationale:
B: Measuring the infant's head circumference is important to assess for signs of increased intracranial pressure, which can be indicated by vomiting.
C: Weighing the infant helps in monitoring for signs of dehydration, which can occur due to vomiting.
D: Monitoring intake and output is essential to assess for dehydration and to track the infant's fluid balance.
Incorrect
Choices:
A: Implementing contact precautions is not necessary for intermittent vomiting as it is not typically related to an infectious process.
E: Offering small, frequent feedings of thickened liquids may exacerbate vomiting if the root cause is not addressed.
F: Evaluating pain level using the FACES scale is not the priority when dealing with vomiting unless there are specific indications.
G: Administering a plain water enema is not appropriate for an infant with vomiting; it can worsen dehydration and electrolyte imbalance.
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Question 2 of 5
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Question 5 of 5
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