Question

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first?

Answer 1

The nurse should first check the baby's vital signs and address any issues causing dehydration or weight loss. The symptoms indicate a potential medical emergency, possibly pyloric stenosis, requiring urgent pediatric assessment.

Step-by-step explanation:

The mother's report that her infant is vomiting "all the time" and the physical assessment findings of poor skin turgor, significant weight loss, and the presence of a palpable abdominal mass suggest that the infant may be experiencing a medical emergency.

The first intervention a nurse should implement is to ensure the baby's vital signs are stable and to prevent further dehydration and weight loss. The clinical assessment findings indicate potential signs of a serious condition such as pyloric stenosis, or another disorder that requires urgent attention. Immediate referral to a pediatrician or emergency care is warranted for further evaluation and treatment. Maintaining the infant's homeostasis is crucial.