A nurse is caring for a 4-month-old infant in the outpatient setting.

Exhibits

Which of the following should the nurse identify as unexpected findings? Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Body system	Findings
Vital Signs	Temperature 36.9°C (98.4° F) Heart rate 162/min Respiratory rate 28/min Oxygen saturation 97% on room air
Gastrointestinal	Also spits up after every feeding, sometimes forcefully. Infant is formula fed and recently began refusing some feedings. Bowel sounds normoactive. Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus. Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz).

Findings that require follow-up:

1. Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
2. Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
3. Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
4. Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

Cough

• Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
• Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

• Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
• Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

• Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
• Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

• Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
• Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.