A nurse is assessing a 6-week-old child for progressive weight loss and projectile vomiting. The nurse suspects pyloric stenosis. What other assessment finding should be expected?

The child accepts a feeding after vomiting

Sausage shaped upper abdominal mass

Jelly- like consistency stools

Severe pain in the abdomen

Answer and Explanation

The Correct Answer is A

A.   Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B.   One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C.   Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D.   While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.

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Correct Answer is B

Explanation

A. Speech and communication abilities are important, but physical safety must come first to prevent accidents or injuries.
B. Safety measures are the highest priority, as children with cognitive impairments may have physical or developmental limitations that increase the risk of falls, accidents, or other harm.
C. Cognitive development and educational needs are important but should be addressed after ensuring
the child’s physical safety.

D. Social and emotional well-being are essential aspects of care, but the immediate focus should be on preventing harm.

A. Otitis Externa B. Otitis Media C. A viral sore throat D. Sinus infection

Correct Answer is B

Explanation

A. Otitis externa, or swimmer's ear, is an infection of the outer ear canal, typically caused by water exposure, and usually presents with itching, discomfort, or drainage rather than fever and ear pain.
B. Otitis media, an infection of the middle ear, is common in children and often presents with symptoms such as fever, ear pain, and irritability. The child’s behavior of crying and rubbing the ear is consistent with this condition.
C. A viral sore throat usually presents with throat pain, fever, and sometimes coughing or congestion, but ear pain is less commonly associated.
D. A sinus infection may cause facial pain, nasal congestion, and discharge but is less likely to present with ear pain and rubbing.

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A nurse is assessing a 6-week-old child for progressive weight loss and projectile vomiting. The nurse suspects pyloric stenosis. What other assessment finding should be expected?

Nursing Test Bank

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