A one-month old baby has been admitted to the pediatric unit with the diagnosis of pyloric stenosis. Which of the following assessments is the highest priority for the nurse to report to the baby's primary health-care provider?

Undigested emesis

Apical heart rate of 156 bpm

Serum potassium of 3.6 mEq/dL

Sunken fontanelle

Answer and Explanation

The Correct Answer is D

A.   Undigested emesis is common in pyloric stenosis and is not the most urgent finding.
B.   An apical heart rate of 156 bpm is elevated, but it is not the most urgent concern compared to dehydration and electrolyte imbalances.
C.   A serum potassium of 3.6 mEq/L is within normal limits, so this is not the most pressing concern for the baby at this time.
D.   A sunken fontanelle is a sign of dehydration, which is a significant and urgent concern in pyloric stenosis. Dehydration can lead to severe complications, so this requires immediate attention.

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Correct Answer is A

Explanation

A. A sudden decrease in abdominal pain is a classic sign of appendiceal rupture or perforation. The pain often decreases after perforation due to the release of pressure from the appendix, but it can worsen once peritonitis develops.
B. A low-grade fever may be present in appendicitis, but it is not a specific indicator of perforation. Fever is more commonly associated with infection or inflammation.
C. Rovsing's sign refers to referred pain in the lower right quadrant when the left side of the abdomen is palpated, and it is present in many cases of appendicitis. Its absence is not a reliable indicator of perforation.
D. A flaccid abdomen is more suggestive of peritonitis, which can occur after perforation. However, a sudden decrease in pain is a stronger sign of perforation.

A. Wheat B. Barley C. Rice D. Rye

Correct Answer is C

Explanation

A. Wheat contains gluten, which is not tolerated by children with celiac disease. It must be avoided to prevent triggering symptoms.
B. Barley also contains gluten and should be excluded from the diet of a child with celiac disease.
C. Rice is naturally gluten-free and is a safe food option for children with celiac disease. It provides a good carbohydrate source and can be part of their balanced diet.
D. Rye contains gluten and should be avoided in the diet of a child with celiac disease.

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A one-month old baby has been admitted to the pediatric unit with the diagnosis of pyloric stenosis. Which of the following assessments is the highest priority for the nurse to report to the baby's primary health-care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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