Author Question: The nurse admits a 9-month-old for a well-baby checkup. The mother tells the nurse she has been ... (Read 63 times)

NClaborn · **on:** Jul 22, 2018

The nurse admits a 9-month-old for a well-baby checkup. The mother tells the nurse she has been adding foods one at a time to the diet, and hasn't encountered any problems. This morning, she noticed a fine, raised rash around the child's mouth.

The nurse asks the mother: 1. Have you introduced any new foods into the diet within the last 24 hours?
2. Have you changed soaps or detergents recently?
3. Has there been any drainage from the area?
4. Does the child drool excessively when sleeping?

Question 2

A postoperative client has a Salem sump nasogastric tube in place. The tube is to be clamped for four hours, reconnected to low intermittent suction for one hour, and then clamped again for four hours.

The client reports increasing nausea after the tube has been clamped for three hours. An appropriate action by the nurse at this time is to: 1. Irrigate the nasogastric tube with 30 milliliters of normal saline.
2. Recheck the position of the nasogastric tube by aspirating for stomach contents.
3. Unclamp the nasogastric tube and reconnect it to low, intermittent suction.
4. Encourage the client to take deep breaths to decrease nausea, and maintain the clamped tube.

jaymee143 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale: The nurse would first determine if there have been any new foods added to the child's diet before questioning about other changes, because food allergies commonly arise when they are introduced into the diet.

Answer to Question 2

3
Rationale: Nausea indicates that gastric motility has not returned sufficient to prevent collection of secretions in the stomach and duodenum. The tube should be reconnected to low, intermittent suction, and the nurse should document the client's response to clamping. Irrigating the tube will increase the client's discomfort, and could result in vomiting. Checking tube placement would be indicated if the client were nauseated while connected to suction, but is not indicted in this situation. Encouraging deep breathing might make the client feel better for a minute but will not resolve the issue causing the sensation, and the tube must be connected to suction.