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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

A. Change position every 2 hours. B. Monitor peripheral pulses and sensation in the right leg. C. Cleanse pin sites as prescribed. D. Assess skin for redness and signs of tissue breakdown.

Correct Answer is B

Explanation

When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the aﬀected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.

Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.

Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

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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?