A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?
Projectile vomiting after feedings.
Absent bowel sounds.
Increased sodium levels.
Golf ball-sized mass over the left quadrant.
The Correct Answer is A
Choice A rationale
Projectile vomiting after feedings is a classic symptom of pyloric stenosis. This occurs because the enlarged pyloric muscle obstructs the passage of food from the stomach to the small intestine.
Choice B rationale
Absent bowel sounds are not typically associated with pyloric stenosis. While this condition affects the gastrointestinal tract, it does not typically cause a complete absence of bowel sounds.
Choice C rationale
Increased sodium levels are not a typical finding in a newborn with pyloric stenosis. In fact, these infants may have low sodium levels due to vomiting.
Choice D rationale
A golf ball-sized mass over the left quadrant is not a typical finding in a newborn with pyloric stenosis. The classic physical examination finding in pyloric stenosis is a palpable “olive-like” mass in the right upper quadrant of the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypotension, or low blood pressure, is a common complication from an epidural block16. This occurs because the medication used in the epidural can block sympathetic nerve fibers, which can cause blood vessels to dilate and lead to a drop in blood pressure16.
Choice B rationale
Vomiting is not typically a direct complication of an epidural block16. Nausea and vomiting during labor can have many causes, including the physical process of labor, pain, and medications.
Choice C rationale
Tachycardia, or a fast heart rate, is not typically a complication of an epidural block16. In fact, some of the medications used in an epidural can actually cause a slower heart rate.
Choice D rationale
While severe respiratory depression can occur with an epidural, it is extremely rare16. More commonly, an epidural can cause a feeling of breathlessness or difficulty taking a deep breath, but it should not cause significant respiratory depression.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Resting in a recliner until the incision is healed is not recommended following a cesarean birth. It’s important for the client to gradually increase their activities and mobility to promote healing and prevent complications such as blood clots.
Choice B rationale
It’s crucial for the client to monitor their incision for signs of infection, such as increased redness, swelling, pain, or discharge. Therefore, calling the provider if there is discharge from the incision indicates understanding of the discharge instructions.
Choice C rationale
Resuming prenatal vitamins is often recommended after a cesarean birth to aid in recovery and support breastfeeding if the client chooses to breastfeed. Prenatal vitamins contain essential nutrients that can help the client heal and recover after surgery.
Choice D rationale
Unrelieved abdominal pain is not a normal part of recovery and could indicate a complication such as an infection or a problem with the incision. Therefore, the client should understand that they should not have unrelieved pain in their abdomen and should contact their provider if they do.
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