Ricci Ch. 42: || 100% Faultless Answers.
An infant brought to the emergency department has been vomiting for 2 days. The nurse assesses
the infant and finds sunken fontanels (fontanelles), tenting skin, dry mucus membranes and no
urine output for 12 hours. Which intervention(s) will the nurse complete as first-line care for this
infant? Select all that apply.
Insert a peripheral IV.
Begin maintenance IV fluids.
Start oral rehydration.
Administer a prescribed IV fluid bolus.
Administer an antiemetic. correct answers Insert a peripheral IV.
Administer a prescribed IV fluid bolus.
Administer an antiemetic.
This infant is showing signs of severe dehydration. These symptoms include sunken fontanels
(fontanelles), tenting of the skin, dry mucus membranes, delayed capillary refill, an increased
heart rate and a urine output of less than 1ml/kg/hr. The nurse will need to insert a peripheral IV
and begin the prescribed bolus IV infusion. After the bolus has been completed, the infant would
need to be reassessed for urine output and symptom improvement. The health care provider
would then prescribe another IV bolus or begin maintenance IV fluids. Antiemetics can be
prescribed if necessary. Oral rehydration is used for mild or moderate dehydration.
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after
every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting
several feet from his mouth. He is always hungry again just after vomiting. At the physician's
office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an
olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?
pyloric stenosis
peptic ulcer disease
gastroesophageal reflux
appendicitis correct answers pyloric stenosis
With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately
after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly
projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because
they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If
pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive
in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood
in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp)
volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours;
children do not eat and do not act like their usual selves. Nausea and vomiting may then occur,
followed by diffuse abdominal pain.
An adolescent has hepatitis B. What would be the most important nursing action?
,Conscientious collection of stool for ova and parasites
Strict calculation of caloric and vitamin B intake
Strict enforcement of standard precautions
Close observation to detect cerebral hallucinations correct answers Strict enforcement of
standard precautions
Hepatitis B is spread through IV drug use, sex, contaminated blood and perinatally. The
treatment is rest, hydration, and nutrition. Hospitalization is required if there is vomiting,
dehydration, elevated bleeding times and mental status changes. The adolescent should be taught
about good hygiene, safe sex practices, careful handwashing and blood/bodily fluid contact
precautions. Using standard precautions of gloves and good handwashing will help prevent
spread of the disease. Ova and parasites are not present with hepatitis B. A good diet with
adequate protein and vitamins will help the body heal, so these should not be restricted. The
nurse observes for mental status changes. These can occur as a complication, but preventing
spread of the disease is the nursing priority.
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting
blood. A medical history determines that the 3-year-old has no history of GI disturbances and his
only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these
symptoms, what condition might the nurse suspect?
GI tract obstruction
intussusception
gastroesophageal reflux
acute upper GI bleeding correct answers acute upper GI bleeding
Vomiting bright red blood indicates acute upper GI bleeding. Emesis containing brown, foul-
smelling stool indicates GI obstruction. Stool with red blood and mucus is associated with
intussusception. Bleeding is not generally indicative of gastroesophageal reflux.
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother
about this condition. Which response from the mother indicates a need for further teaching?
"I can tape a quarter over the hernia to reduce it."
"An incarcerated hernia is rare, but it can occur."
"I need to watch for pain, tenderness, or redness."
"My son could have some appearance-related self-esteem issues." correct answers "I can tape a
quarter over the hernia to reduce it."
The use of home remedies to reduce an umbilical hernia should be discouraged because of the
risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is
rare with an umbilical hernia. Pain, tenderness, or redness indicates an incarcerated hernia, which
although rare with umbilical hernias, can occur.She needs to understand the signs of
strangulation and understand that some children have self-esteem issues related to the large
protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any
, types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of
an unrepaired umbilical hernia.
The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which
action will the nurse take when administering a prescribed feeding through the client's G-tube?
Check for gastric residual before starting feeding.
Position the client with the head of the bed at a 20° angle.
Use a syringe plunger to administer the feeding.
After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2
minutes. correct answers Check for gastric residual before starting feeding.
The nurse should check for gastric residual before starting feeding by gently aspirating from the
tube with a syringe or positioning the tube below the level of the stomach with only the barrel of
the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and
the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After
feeding, the nurse should flush the tube with a small amount of water, unless contraindicated,
and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.
The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires
about the testing required to evaluate the condition. How should the nurse respond?
"You will most likely have a blood test to check for certain antibodies."
"You will most likely have an ultrasound evaluation."
"You will most likely have viral studies."
"You will most likely be tested for ammonia levels." correct answers "You will most likely have
a blood test to check for certain antibodies."
Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune
hepatitis. Ultrasound is performed to assess for liver or spleen abnormalities. Viral studies are
performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic
encephalopathy is suspected.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The
mother is attempting to feed the baby, but does not make eye contact. The father is watching
television with his back turned to the mother and baby. What psychosocial nursing intervention
would be most helpful to this family?
Ask the parents if they have any questions regarding the care of their child.
Explain to the parents that surgical intervention will fix the defect in the baby's lip.
Teach the mother the appropriate technique for breastfeeding an infant with cleft lip.
Refer the family to a social worker or mental health practitioner. correct answers Ask the parents
if they have any questions regarding the care of their child.
An infant brought to the emergency department has been vomiting for 2 days. The nurse assesses
the infant and finds sunken fontanels (fontanelles), tenting skin, dry mucus membranes and no
urine output for 12 hours. Which intervention(s) will the nurse complete as first-line care for this
infant? Select all that apply.
Insert a peripheral IV.
Begin maintenance IV fluids.
Start oral rehydration.
Administer a prescribed IV fluid bolus.
Administer an antiemetic. correct answers Insert a peripheral IV.
Administer a prescribed IV fluid bolus.
Administer an antiemetic.
This infant is showing signs of severe dehydration. These symptoms include sunken fontanels
(fontanelles), tenting of the skin, dry mucus membranes, delayed capillary refill, an increased
heart rate and a urine output of less than 1ml/kg/hr. The nurse will need to insert a peripheral IV
and begin the prescribed bolus IV infusion. After the bolus has been completed, the infant would
need to be reassessed for urine output and symptom improvement. The health care provider
would then prescribe another IV bolus or begin maintenance IV fluids. Antiemetics can be
prescribed if necessary. Oral rehydration is used for mild or moderate dehydration.
A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after
every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting
several feet from his mouth. He is always hungry again just after vomiting. At the physician's
office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an
olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?
pyloric stenosis
peptic ulcer disease
gastroesophageal reflux
appendicitis correct answers pyloric stenosis
With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately
after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly
projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because
they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If
pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive
in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood
in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp)
volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours;
children do not eat and do not act like their usual selves. Nausea and vomiting may then occur,
followed by diffuse abdominal pain.
An adolescent has hepatitis B. What would be the most important nursing action?
,Conscientious collection of stool for ova and parasites
Strict calculation of caloric and vitamin B intake
Strict enforcement of standard precautions
Close observation to detect cerebral hallucinations correct answers Strict enforcement of
standard precautions
Hepatitis B is spread through IV drug use, sex, contaminated blood and perinatally. The
treatment is rest, hydration, and nutrition. Hospitalization is required if there is vomiting,
dehydration, elevated bleeding times and mental status changes. The adolescent should be taught
about good hygiene, safe sex practices, careful handwashing and blood/bodily fluid contact
precautions. Using standard precautions of gloves and good handwashing will help prevent
spread of the disease. Ova and parasites are not present with hepatitis B. A good diet with
adequate protein and vitamins will help the body heal, so these should not be restricted. The
nurse observes for mental status changes. These can occur as a complication, but preventing
spread of the disease is the nursing priority.
A mother brings her 3-year-old son to the ER and tells the triage nurse that he has been vomiting
blood. A medical history determines that the 3-year-old has no history of GI disturbances and his
only symptoms are a slightly elevated fever and vomiting bright red blood. Based on these
symptoms, what condition might the nurse suspect?
GI tract obstruction
intussusception
gastroesophageal reflux
acute upper GI bleeding correct answers acute upper GI bleeding
Vomiting bright red blood indicates acute upper GI bleeding. Emesis containing brown, foul-
smelling stool indicates GI obstruction. Stool with red blood and mucus is associated with
intussusception. Bleeding is not generally indicative of gastroesophageal reflux.
The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother
about this condition. Which response from the mother indicates a need for further teaching?
"I can tape a quarter over the hernia to reduce it."
"An incarcerated hernia is rare, but it can occur."
"I need to watch for pain, tenderness, or redness."
"My son could have some appearance-related self-esteem issues." correct answers "I can tape a
quarter over the hernia to reduce it."
The use of home remedies to reduce an umbilical hernia should be discouraged because of the
risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is
rare with an umbilical hernia. Pain, tenderness, or redness indicates an incarcerated hernia, which
although rare with umbilical hernias, can occur.She needs to understand the signs of
strangulation and understand that some children have self-esteem issues related to the large
protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any
, types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of
an unrepaired umbilical hernia.
The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which
action will the nurse take when administering a prescribed feeding through the client's G-tube?
Check for gastric residual before starting feeding.
Position the client with the head of the bed at a 20° angle.
Use a syringe plunger to administer the feeding.
After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2
minutes. correct answers Check for gastric residual before starting feeding.
The nurse should check for gastric residual before starting feeding by gently aspirating from the
tube with a syringe or positioning the tube below the level of the stomach with only the barrel of
the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and
the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After
feeding, the nurse should flush the tube with a small amount of water, unless contraindicated,
and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.
The nurse is caring for a 13-year-old girl with suspected autoimmune hepatitis. The girl inquires
about the testing required to evaluate the condition. How should the nurse respond?
"You will most likely have a blood test to check for certain antibodies."
"You will most likely have an ultrasound evaluation."
"You will most likely have viral studies."
"You will most likely be tested for ammonia levels." correct answers "You will most likely have
a blood test to check for certain antibodies."
Anti-nuclear antibodies are one of the diagnostic tests performed to diagnose autoimmune
hepatitis. Ultrasound is performed to assess for liver or spleen abnormalities. Viral studies are
performed to screen for viral causes of hepatitis. Ammonia levels may be ordered if hepatic
encephalopathy is suspected.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The
mother is attempting to feed the baby, but does not make eye contact. The father is watching
television with his back turned to the mother and baby. What psychosocial nursing intervention
would be most helpful to this family?
Ask the parents if they have any questions regarding the care of their child.
Explain to the parents that surgical intervention will fix the defect in the baby's lip.
Teach the mother the appropriate technique for breastfeeding an infant with cleft lip.
Refer the family to a social worker or mental health practitioner. correct answers Ask the parents
if they have any questions regarding the care of their child.
