A nurse is caring for a 6-week-old infant who has hypertrophic pyloric stenosis (HPS). Which of the following clinical manifestations should the nurse expect?

Ridged abdomen

Distended neck veins

Red currant jelly stools

Projectile vomiting

Answer and Explanation

The Correct Answer is D

A. Rigid abdomen: A rigid abdomen is not a common finding in HPS. However, it is more typical in conditions such as intestinal obstruction.

B. Distended neck veins: Distended neck veins are not a typical manifestation of HPS. They may be associated with other cardiovascular or respiratory issues.

C. Red currant jelly stools: Red currant jelly-like stools are not typically seen in HPS. This description is often used to describe the appearance of stools in intussusception, which is a different gastrointestinal condition.

D. Projectile vomiting.

Hypertrophic pyloric stenosis is a condition in infants where the muscle at the outlet of the stomach (pylorus) becomes thickened and obstructs the passage of food from the stomach into the small intestine. Projectile vomiting is a characteristic symptom of HPS. The vomit is forceful and seems to shoot out of the infant's mouth, typically occurring after feeding.

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Correct Answer is C

Explanation

A. Inspecting the mouth weekly for ulcerations is not sufficient. Children receiving chemotherapy should be encouraged to perform daily oral care, and any concerning symptoms should be reported promptly to the healthcare provider.

B. Using a potent commercial mouthwash is not recommended, as many commercial mouthwashes contain alcohol or other potentially irritating ingredients. A healthcare provider should recommend a suitable oral rinse if needed.

C. Clean the teeth manually with a soft toothbrush.

Children receiving chemotherapy are at risk of developing mouth sores (mucositis) and other oral complications. It is essential to maintain good oral hygiene to minimize the risk of infection and reduce discomfort. Using a soft toothbrush for gentle manual cleaning is recommended, as it helps to prevent injury to the sensitive oral tissues that can occur with a hard toothbrush.

D. Visiting a dental professional only during episodes of excessive bleeding or pain is not recommended. Regular dental check-ups are important for children receiving chemotherapy to monitor and address oral health issues. Waiting for symptoms of bleeding or pain may result in a delay in addressing potential problems.

A. Monitoring level of consciousness (LOC) B. Administration of IV antibiotics C. Decreasing environmental stimuli D. Increasing TV fluids above the maintenance E. Instituting droplet precautions

Correct Answer is ["A","B","C","E"]

Explanation

A. Monitoring level of consciousness (LOC): Monitoring the child's level of consciousness is essential as changes in LOC can be an important indicator of the progression of meningitis.

B. Administration of IV antibiotics: Antibiotics are a critical component of the treatment for bacterial meningitis. Early administration of appropriate antibiotics is crucial to control the infection.

C. Decreasing environmental stimuli: Reducing environmental stimuli, such as noise and light, can help minimize discomfort and agitation in a child with meningitis.

D. Increasing IV fluids above maintenance is not typically part of the standard management of bacterial meningitis. Maintaining hydration and electrolyte balance is important, but increasing fluids significantly above maintenance may not be necessary and should be determined based on the child's clinical condition.

E. Instituting droplet precautions: Bacterial meningitis is contagious, and it is important to isolate the child and implement appropriate infection control measures, including droplet precautions, to prevent the spread of the infection to others.

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A nurse is caring for a 6-week-old infant who has hypertrophic pyloric stenosis (HPS). Which of the following clinical manifestations should the nurse expect?

Nursing Test Bank

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Correct Answer is C

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