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
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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Torticollis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes tilting or twisting of the neck due to contraction or spasm of the sternocleidomastoid muscle. Torticollis can cause pain, stiffness, or limited range of motion in the neck. Torticollis can be congenital or acquired due to injury, infection, or posture.
Choice B: Lordosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive inward curvature of the lower spine. Lordosis can cause back pain, stiffness, or difficulty in movement. Lordosis can be congenital or acquired due to obesity, pregnancy, osteoporosis, or spondylolisthesis.
Choice C: Kyphosis is not a disorder that causes lateral curvature of the spine, but rather a condition that causes excessive outward curvature of the upper spine. Kyphosis can cause a hunchback appearance, back pain, stiffness, or breathing problems. Kyphosis can be congenital or acquired due to aging, osteoporosis, arthritis, or spinal injury.
Choice D: Scoliosis is a disorder that causes lateral curvature of the spine in one or more places. Scoliosis can cause uneven shoulders or hips, back pain, fatigue, or breathing problems. Scoliosis can be congenital or idiopathic (unknown cause). Scoliosis can be diagnosed by physical examination and X-ray and treated by braces or surgery depending on the severity and progression of the curve.

Correct Answer is A
Explanation
Choice A: An ostomy is a surgical opening in the abdomen that allows stool to pass out of the body. A child who has Hirschsprung disease, which is a condition that causes a blockage of the large intestine due to a lack of nerve cells, may need an ostomy to relieve the obstruction and prevent complications. The ostomy is usually temporary and can be reversed after the affected part of the intestine is removed or repaired. This statement indicates an understanding of the teaching, as the parent knows that the ostomy is not permanent.
Choice B: A urinary catheter is a tube that drains urine from the bladder. A child who has Hirschsprung disease does not need a urinary catheter, as their condition does not affect their urinary system. This statement indicates a lack of understanding of the teaching, as the parent is confused about the type of surgery or device that their child will have.
Choice C: A feeding tube is a tube that delivers nutrition directly into the stomach or small intestine. A child who has Hirschsprung disease may need a feeding tube if they have severe malnutrition, dehydration, or infection due to their condition. However, this is not always necessary and depends on the individual case and the surgeon's preference.
This statement indicates a lack of understanding of the teaching, as the parent assumes that their child will need a feeding tube without knowing the specific plan.
Choice D: A child who has Hirschsprung disease will not have normal bowel movements after the initial surgery, as they will still have an ostomy that bypasses their large intestine. They will need another surgery to reconnect their intestine and restore their bowel function. This statement indicates a lack of understanding of the teaching, as the parent has unrealistic expectations about the outcome of the surgery.

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