An infant diagnosed with pyloric stenosis recently developed projectile vomiting. Which finding indicates to the practical nurse that the infant is becoming dehydrated?
Bulging fontanel.
Weak cry without any tears.
Visible peristaltic wave.
Palpable mass in the right upper quadrant.
The Correct Answer is B
A. Bulging fontanel: A bulging fontanel may indicate increased intracranial pressure rather than dehydration. In dehydration, the fontanel is typically sunken rather than bulging.
B. Weak cry without any tears: Absence of tears when crying and a weak cry are classic signs of dehydration in infants. These findings indicate fluid loss and inadequate hydration, which is especially concerning in conditions like pyloric stenosis with frequent vomiting.
C. Visible peristaltic wave: A visible peristaltic wave across the abdomen is characteristic of pyloric stenosis itself but does not indicate dehydration. It reflects gastric contractions trying to move contents past the narrowed pylorus.
D. Palpable mass in the right upper quadrant: The palpable “olive-shaped” mass in the right upper quadrant is a hallmark diagnostic finding for pyloric stenosis but is unrelated to the infant’s hydration status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Brown spots on hands and arms: These are common age-related changes (lentigines) and are not an urgent concern related to hot pack use or psoriatic care.
B. Areas of decreased pigmentation: Hypopigmentation can occur in psoriasis or with chronic skin changes, but it is not typically a sign of acute injury or complication from heat therapy.
C. Erythema and edematous areas: Redness and swelling indicate possible skin irritation or burns from hot packs. These findings require prompt referral to the charge nurse for assessment and intervention to prevent further injury or infection.
D. Yellow-white scales on the skin: These are characteristic of psoriatic plaques and are expected findings. They do not signal a complication from the heat therapy and do not require immediate referral.
Correct Answer is C
Explanation
A. On the same side as the affected extremity: Placing the cane on the affected side reduces stability because the weaker side does not provide sufficient support. This increases the risk of falls and improper gait.
B. Approximately one foot away from the body to stabilize balance: Holding the cane too far from the body can compromise balance and coordination. Proper cane placement should maintain stability close to the body while allowing natural movement.
C. On the opposite side of the affected extremity: The cane should be held on the side opposite the weaker or affected limb. This provides optimal support and balance during ambulation, allowing the client to bear weight safely while stepping forward with the affected leg.
D. In front of the body to lean on while stepping forward: Leaning on the cane excessively shifts weight forward and can destabilize the client. The cane is intended to provide lateral support rather than function as a crutch for leaning.
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