a child with pyloric stenosis is having excessive vomiting the nurse should assess for what potential complication
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

Correct answer: D

Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.

2. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?

Correct answer: C

Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.

3. A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate?

Correct answer: C

Rationale: Aplastic anemia is a condition where the bone marrow fails to produce sufficient red blood cells, white blood cells, and platelets, leading to pancytopenia. This can result in fatigue, infections, and bleeding tendencies. It is not characterized by abnormal red blood cell shapes, but rather by a reduction in the production of blood cells. Therefore, the accurate response is that aplastic anemia is caused by the bone marrow producing inadequate cells. Choices A and B are incorrect as aplastic anemia does not cause a proliferation of white blood cells or involve abnormally shaped red blood cells. Choice D is incorrect as aplastic anemia is not typically a disorder that occurs after a viral illness.

4. The nurse is providing education to the parent of a child with Beta-thalassemia. Which risk factors about the condition should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D: Chronic hypoxia and iron overload. Children with Beta-thalassemia often suffer from chronic hypoxia due to ineffective erythropoiesis and require frequent blood transfusions, leading to iron overload. These complications must be managed to prevent organ damage. Choices A, B, and C are incorrect. Hypertrophy of the thyroid, polycythemia vera, and thrombocytopenia are not direct risk factors associated with Beta-thalassemia. Therefore, they should not be included in the teaching regarding this condition.

5. The parent of an infant with colic tells the nurse, "All this baby does is scream at me; it is a constant worry." What is the nurse's best action?

Correct answer: A

Rationale: Encouraging the parent to express their feelings is crucial in providing support and addressing the emotional challenges that colic can present. Reassuring the parent about the temporary nature of colic can also be helpful.

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