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
Always seems full
Projectile vomiting
Excessive weight gain
The Correct Answer is C
A. Presence of Dance sign. – Incorrect. Dance sign (absence of bowel sounds in the right lower quadrant) is associated with intussusception, not pyloric stenosis.
B. Always seems full. – Incorrect. Babies with pyloric stenosis initially feed well but develop progressive vomiting and hunger after feeds.
C. Projectile vomiting. – Correct. Pyloric stenosis causes forceful, non-bilious projectile vomiting due to gastric outlet obstruction.
D. Excessive weight gain. – Incorrect. Infants with pyloric stenosis typically experience weight loss or poor weight gain due to vomiting.
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Related Questions
Correct Answer is D
Explanation
A. Place the child on a no-salt-added diet. – Important but not the priority. Sodium restriction helps control fluid retention, but monitoring fluid balance is more critical.
B. Educate the parents about potential complications. – Important but not the first action. Early detection of complications through monitoring is more urgent.
C. Maintain a saline-lock for possible medications. – Useful but not the highest priority. Monitoring for fluid overload takes precedence.
D. Check the child’s daily weight. – Correct. Daily weight monitoring is the most effective way to assess fluid retention and worsening kidney function in acute glomerulonephritis.
Correct Answer is C
Explanation
A. Trauma to the head or neck area causing a concussion. – Incorrect. Febrile seizures are not caused by trauma.
B. Structural brain lobe defect since birth. – Incorrect. Febrile seizures are not related to congenital brain defects.
C. Sudden rise in body temperature due to inflammation or infection. – Correct. Febrile seizures occur when a child’s temperature rises rapidly, often due to a viral or bacterial infection.
D. Pooling of blood in a cerebral space. – Incorrect. This refers to intracranial hemorrhage, not febrile seizures.
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