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

Answer and Explanation

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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Correct Answer is B

Explanation

A. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me."

This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it.

B. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."

This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns.

C. "I will discuss your child's loss of bladder control with the provider."

This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance.

D. "Why is she wetting the bed in the hospital? She must wet the bed at home."

This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.

A. Reports of exposure to a skin irritant B. Elevated temperature C. Denial of pruritus D. Reports of joint discomfort

Correct Answer is A

Explanation

A. Reports of exposure to a skin irritant:

This finding is consistent with contact dermatitis, as it typically occurs due to exposure to irritants or allergens. Therefore, it is an expected finding.

B. Elevated temperature:

Elevated temperature is not typically associated with contact dermatitis unless there is a secondary infection. It is not a typical finding in uncomplicated contact dermatitis.

C. Denial of pruritus:

Pruritus, or itching, is a common symptom of contact dermatitis. Clients with contact dermatitis often experience itching or discomfort in the affected area. Therefore, denial of pruritus would be an unexpected finding.

D. Reports of joint discomfort:

Joint discomfort is not typically associated with contact dermatitis. Contact dermatitis primarily affects the skin and does not usually involve the joints. Therefore, reports of joint discomfort would be an unexpected finding.

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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?

Nursing Test Bank

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