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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

A. Postpartum hemorrhage. B. Postpartum infection. C. Hypertension. D. Thromboembolic events.

Correct Answer is A

Explanation

Choice A rationale

Methylergonovine is a medication used to prevent postpartum hemorrhage. It works by causing the uterus to contract, which helps to control bleeding and expel any remaining placental fragments.

Choice B rationale

While infection control is important in the postpartum period, methylergonovine is not specifically used to prevent postpartum infection.

Choice C rationale

Methylergonovine does not prevent hypertension. In fact, it can cause hypertension as a side effect.

Choice D rationale

Methylergonovine is not used to prevent thromboembolic events. Its primary use is to prevent and control postpartum hemorrhage.

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A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is 36 hours postpartum. Exhibits After reviewing the information in the patient’s medical record, which of the following complications pose a greater risk for the patient?

Correct Answer is C

Explanation

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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