The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings.
Which additional finding should the nurse expect to assess?
Rebound tenderness in the left lower abdominal quadrant.
Stool that consists of mucus and blood.
Olive-size mass in the epigastric area.
Frequent burping accompanied by poor feeding.
The Correct Answer is C
In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the flow of food into the small intestine becomes thickened and narrowed.
Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks
A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings
B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination
C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.
Correct Answer is C
Explanation
During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the affected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.
Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.
Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.
Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.
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