A nurse is caring for an infant whose guardian reports intermittent vomiting for several days. Findings upon admission: Exhibits Which of the following actions should the nurse take? (Select all that apply)
Explanation & Rationale
A. Contact precautions are not indicated unless there is an infectious disease concern, which is not mentioned in this scenario. B. Head circumference is routine for well-baby visits and neurological conditions (e.g., hydrocephalus). It is not related to pyloric stenosis assessment. C. Regular weighing is crucial to assess for weight loss due to vomiting and dehydration. Monitoring weight helps evaluate the severity of the infant's condition and the effectiveness of ongoing treatment. D. Tracking intake and output is essential for managing hydration status and ensuring the infant is receiving adequate fluids. It helps in assessing the balance between fluid loss due to vomiting and fluid replacement. E. This intervention is not appropriate for hypertrophic pyloric stenosis. The primary treatment for this condition is surgical intervention, and feeding changes alone will not resolve the underlying issue. F. The FACES scale is typically used for older children who can self-report pain. For an infant, alternative pain assessment methods would be used, such as observing behavioral cues. G. An enema is not indicated for hypertrophic pyloric stenosis and may worsen the infant's condition. The focus should be on hydration and surgical preparation rather than enemas.