A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
Projectile vomiting
Metabolic acidosis
Effortless regurgitation
Distended abdomen
The Correct Answer is A
A. Projectile vomiting
Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents.
B. Metabolic acidosis
Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly.
C. Effortless regurgitation
Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents.
D. Distended abdomen
A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Lice do not survive away from the host."
- This statement is incorrect. Lice can survive away from the host (human scalp) for a limited period, usually up to 1-2 days. They may be found on items such as bedding, clothing, hats, or hair accessories. Therefore, proper cleaning and disinfection of these items are essential to prevent the spread of lice.
B. "Washing your child's hair daily will prevent lice."
- This statement is incorrect. While maintaining good hygiene is important, washing hair daily does not necessarily prevent lice infestation. Lice infestations occur through direct head-to-head contact with an infested person, not due to uncleanliness. Additionally, lice are more commonly found in clean hair rather than dirty hair.
C. "Encourage your child to avoid sharing hats with other children."
- This statement is correct. Sharing personal items such as hats, scarves, brushes, or hair accessories can facilitate the spread of lice from one person to another. Therefore, it's important to advise children not to share these items to reduce the risk of lice transmission.
D. "Lice can jump from one child to another."
- This statement is incorrect. Lice do not have the ability to jump or fly. They spread through direct contact with the hair or scalp of an infested person. However, they can crawl quickly from one person to another, especially when there is close contact, such as during play or when sharing personal items.
Correct Answer is B
Explanation
A. Measuring the child's chest circumference:
Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen.
B. Palpating the child's abdomen:
This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor.
C. Measuring the child's occipitofrontal circumference:
This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor.
D. Placing the child in an upright position:
Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
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