a child is admitted with suspected pyloric stenosis which of the following should be included in the plan of care

ATI RN

ATI Nursing Care of Children

1. A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?

A. Monitor for signs of metabolic acidosis
B. Observe for projectile vomiting
C. Provide large, infrequent feedings to allow for rest
D. Place the infant in a supine position after feeding

Correct answer: B

Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.

2. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?

A. Steatorrhea
B. Clay-colored
C. Currant jelly-like
D. Loose stools with undigested food

Correct answer: C

Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.

3. Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?

A. ''We're glad the dog can continue to sleep in our child’s room.''
B. ''We’ll keep the plants in our child’s room dusted.''
C. ''We’ll be sure to use the fireplace often to keep the house warm in the winter.''
D. ''We will replace the carpet in our child’s bedroom with a hard surface.''

Correct answer: D

Rationale: The correct answer is D. Replacing carpet with hard flooring helps to reduce allergens and asthma triggers in the child’s environment. Choice A is incorrect as having a dog in the child’s room can worsen asthma symptoms due to pet dander. Choice B is incorrect because keeping plants in the child’s room can increase mold spores and allergens. Choice C is incorrect as using a fireplace can introduce smoke and other irritants into the air, worsening asthma symptoms.

4. Which situation denotes a nontherapeutic nurse-patient-family relationship?

A. The nurse is planning to read a favorite fairy tale to a patient
B. During shift report, the nurse is criticizing parents for not visiting their child
C. The nurse is discussing with a fellow nurse the emotional draw to a certain patient
D. The nurse is working with a family to find ways to decrease the family’s dependence on health care providers

Correct answer: B

Rationale: Criticizing parents or making negative comments about their involvement is nontherapeutic and can damage the nurse-patient-family relationship.

5. What time frame has the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommended that pregnant adolescents and women who are not protected against pertussis receive the tetanus, diphtheria, and pertussis (Tdap) vaccine?

A. Between 27 and 36 weeks of gestation or postpartum before discharge from the hospital
B. During the first prenatal visit when pregnancy is confirmed
C. The vaccine should be administered 24 hours prior to delivery
D. This vaccine is only recommended during the first trimester

Correct answer: A

Rationale: The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommend that pregnant adolescents and women without protection against pertussis should receive the Tdap vaccine ideally between 27 and 36 weeks of gestation or postpartum before discharge from the hospital. This timeframe allows for the development of antibodies in the mother to protect her and provide passive immunity to the infant. Administering the vaccine during the first trimester (Choice D) is not recommended as the optimal time is between 27 and 36 weeks. Choice B, during the first prenatal visit, is too early for optimal protection, and Choice C, 24 hours prior to delivery, does not provide enough time for the vaccine to be effective before birth.