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

Distended neck veins

Rigid abdomen

Projectile vomiting

Red currant jelly stools

Answer and Explanation

The Correct Answer is C

Choice A: Distended neck veins are not a clinical manifestation of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Distended neck veins are a sign of increased venous pressure, which can occur in conditions that affect the right side of the heart or cause ﬂuid overload.

Choice B: Rigid abdomen is not a clinical manifestation of pyloric stenosis, but rather a sign of peritonitis, which is inﬂammation of the peritoneum, which is the membrane that lines the abdominal cavity. Peritonitis can be caused by infection, perforation, or trauma to any abdominal organ. A rigid abdomen indicates severe pain and inﬂammation in the abdominal cavity.

Choice C: Projectile vomiting is a clinical manifestation of pyloric stenosis, as it indicates forceful expulsion of stomach contents due to obstruction at the pylorus. Projectile vomiting can occur shortly after feeding and may contain undigested milk or formula. Projectile vomiting can cause dehydration, electrolyte imbalance, or weight loss.

Choice D: Red currant jelly stools are not a clinical manifestation of pyloric stenosis, but rather a sign of intussusception, which is a condition that causes telescoping of one segment of bowel into another. Intussusception can cause obstruction and ischemia of the bowel and lead to bleeding and necrosis. Red currant jelly stools indicate blood and mucus in the stool.

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Correct Answer is C

Explanation

Choice A: A popping sensation when swallowing is not a sign of a tympanic membrane rupture, as it is a normal phenomenon that occurs when the eustachian tube opens and closes to equalize the pressure between the middle ear and the atmosphere. A popping sensation when swallowing may be associated with otitis media with eﬀusion, which is a condition that causes ﬂuid accumulation behind the eardrum, but it does not indicate a rupture.

Choice B: Green-blue discharge could be indicative of infection but is not as directly related to the rupture event as the sudden pain relief is.

Choice C: The correct answer is sudden relief of pain. This is because the rupture of the tympanic membrane releases the pressure and fluid that has built up in the middle ear, leading to an immediate decrease in pain.

Choice D: An increased temperature is not a sign of a tympanic membrane rupture, as it is a nonspecific symptom that may indicate various conditions, such as inﬂammation, infection, or fever. An increased temperature may be associated with otitis media with eﬀusion, which is a condition that causes ﬂuid accumulation behind the eardrum, but it does not indicate a rupture.

A. 3 years B. 4 years C. 5 years D. 6 years

Correct Answer is B

Explanation

Choice A: A 3-year-old child is not developmentally ready to descend stairs by placing both feet on each step and holding on to the railing. A 3-year-old child can walk up stairs alternating feet with one hand held by an adult or on the railing. A 3-year-old child can also walk down stairs placing both feet on each step with one hand held by an adult.

Choice B: A 4-year-old child is developmentally able to descend stairs by placing both feet on each step and holding on to the railing. A 4-year-old child can also walk up stairs alternating feet without assistance.

Choice C: A 5-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 5-year-old child can walk up and down stairs alternating feet without assistance.

Choice D: A 6-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 6-year-old child can walk up and down stairs alternating feet without assistance and can also hop and skip on one foot.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has otitis media with eﬀusion. The nurse should identify which of the following manifestations indicates a tympanic membrane rupture.

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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