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 B

Explanation

When using an ophthalmic anti-infective ointment, it is important to prepare the child for blurry vision after ointment application. This is because the ointment can temporarily blur vision after application. It is important to follow the instructions on the medication label and continue using the ointment for the full course of treatment, even if symptoms improve before then ¹.

A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process. B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage. C. Administer the injection into the middle of the lateral aspect of the thigh. D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.

Correct Answer is C

Explanation

Administer the injection into the middle of the lateral aspect of the thigh is the correct choice. This is the recommended site for intramuscular injection in toddlers who have been walking for at least one month, as it is a large muscle with minimal nerves and blood vessels. Choices A, B, and D are not appropriate techniques for administering an intramuscular injection to a toddler with pneumonia.

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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?

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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?