A nurse is caring for a newborn who may have pyloric stenosis. Which of the following manifestations should the nurse expect?

Presence of Dance sign

Projectile vomiting

Always seems full

Excessive weight gain

Answer and Explanation

The Correct Answer is B

A. Presence of Dance sign. Dance sign (an empty right lower quadrant on palpation) is associated with intussusception, not pyloric stenosis. Pyloric stenosis is characterized by hypertrophy of the pyloric sphincter, leading to gastric outlet obstruction.

B. Projectile vomiting. Forceful, non-bilious projectile vomiting is the hallmark symptom of pyloric stenosis. It occurs due to the narrowing of the pyloric sphincter, preventing stomach contents from passing into the small intestine. Vomiting usually begins around 2 to 6 weeks of age and worsens over time.

C. Always seems full. Infants with pyloric stenosis actually experience hunger and irritability after vomiting because food is not reaching the intestines for digestion and absorption.

D. Excessive weight gain. Instead of gaining weight, infants with pyloric stenosis often experience weight loss or poor weight gain due to repeated vomiting and inadequate nutrient absorption.

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Correct Answer is A

Explanation

A. "Screening involves a combination of parent interviews, observations, and standardized developmental screening tools." The diagnosis of autism spectrum disorder (ASD) is based on behavioral assessments, including parent-reported history, clinical observations, and standardized screening tools such as the Modified Checklist for Autism in Toddlers (M-CHAT).

B. "ASD can be definitively diagnosed with a simple blood test, so we will schedule one for your child." There is no blood test or biomarker that can diagnose ASD. Diagnosis is based on behavioral and developmental criteria rather than laboratory tests.

C. "The screening process for ASD is usually completed in one visit to the healthcare provider." ASD screening and diagnosis require multiple evaluations over time, often involving developmental specialists, psychologists, and speech therapists to get a comprehensive understanding of the child’s behaviors.

D. "If your child makes eye contact with you, we can rule out autism spectrum disorder." While reduced eye contact is a common characteristic of ASD, some children with ASD do make eye contact, and the presence or absence of this behavior alone does not confirm or rule out the disorder.

A. An electrical source B. Contact with hot liquid C. A mild sunburn D. Contact with a flame

Correct Answer is B

Explanation

A. An electrical source. Electrical burns often cause deep tissue damage that may not be visible on the surface. These burns can extend beyond the skin, affecting muscles, nerves, and internal organs, making them more severe than partial-thickness burns.

B. Contact with hot liquid. Scald burns from hot liquids (e.g., boiling water, coffee, soup) are a common cause of partial-thickness burns. These burns affect the epidermis and part of the dermis, leading to blistering, redness, and pain.

C. A mild sunburn. Mild sunburns typically cause superficial burns (first-degree burns), affecting only the epidermis and resulting in redness and discomfort without blisters. Partial-thickness burns involve deeper skin layers.

D. Contact with a flame. Direct contact with a flame is more likely to cause deeper burns, often resulting in full-thickness burns (third-degree) rather than partial-thickness burns.

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A nurse is caring for a newborn who may have pyloric stenosis. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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