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 A
Explanation
Choice A:In actual practice, log rolling is typically done every 2 hoursto align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT).
as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff
members to assist with log rolling.
Choice B: This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.
Choice C: This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. The nurse should follow standard precautions and surgical site care to prevent infection in this client.
Choice D: This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.
Correct Answer is D
Explanation
Choice A: Polyuria is not a finding of nephrotic syndrome, but rather a finding of diabetes mellitus or diabetes insipidus. Polyuria means excessive urination, which can cause dehydration and electrolyte imbalance.
Choice B: Smoky brown urine is not a finding of nephrotic syndrome, but rather a finding of acute glomerulonephritis or hemolytic uremic syndrome. Smoky brown urine means that there is blood in the urine, which can indicate damage to the glomeruli, the filtering units of the kidneys.
Choice C: Hypertension is not a finding of nephrotic syndrome, but rather a finding of chronic kidney disease or renal artery stenosis. Hypertension means high blood pressure, which can cause damage to the blood vessels and organs.
Choice D: Facial edema is a common finding of nephrotic syndrome, as nephrotic syndrome is a condition in which the kidneys leak large amounts of protein into the urine, causing low blood protein levels and fluid retention. Facial edema means swelling of the face, especially around the eyes, which can occur due to gravity and fluid shifts.
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