The nurse is caring for a 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?

Stool containing mucus and blood.

An olive-sized mass in the epigastric region.

Frequent burping accompanied by poor feeding.

Rebound tenderness in the left lower abdominal quadrant.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it’s possible for an infant with projectile vomiting to have stool containing mucus and blood, this is not typically associated with the condition that most commonly causes projectile vomiting in infants, which is pyloric stenosis.
Choice B rationale
An olive-sized mass in the epigastric region is a classic symptom of pyloric stenosis. This condition occurs when the muscle between the stomach and the small intestine (the pylorus) thickens, preventing food from moving from the stomach to the intestine.
Choice C rationale
Frequent burping and poor feeding can be symptoms of many different conditions in infants, but they are not typically associated with pyloric stenosis.
Choice D rationale
Rebound tenderness in the left lower abdominal quadrant is a symptom of conditions like appendicitis, but it is not typically associated with pyloric stenosis.

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Correct Answer is B

Explanation

Choice A rationale
While infant formula is a common feeding option, it does not enhance the absorption of iron. In fact, iron is better absorbed when taken with vitamin C, which is abundant in orange juice.
Choice B rationale
The mother is correctly administering the iron drops. Giving iron with orange juice can enhance iron absorption due to the vitamin C content.
Choice C rationale
Mixing the iron drops in the orange juice is not necessary and could potentially alter the taste of the juice.
Choice D rationale
There is no need to refrain from feeding the infant for 30 minutes after giving the iron drops.

A. Hypotension and tachycardia B. Vigorous feeding and satiation C. Fever D. Hemiplegia

Correct Answer is A

Explanation

Choice A rationale
In an infant with aortic stenosis and bilateral fine crackles in both lung fields, hypotension and tachycardia are additional findings that the nurse should expect to observe. Aortic stenosis can lead to decreased cardiac output, which can result in hypotension. The body compensates for this by increasing the heart rate, leading to tachycardia.
Choice B rationale
Vigorous feeding and satiation are not typically associated with aortic stenosis. Infants with aortic stenosis may actually have difficulty feeding due to fatigue.
Choice C rationale
Fever is not a typical symptom of aortic stenosis. If an infant with aortic stenosis has a fever, it may indicate a concurrent infection.
Choice D rationale
Hemiplegia, or paralysis of one side of the body, is not a typical symptom of aortic stenosis. If an infant with aortic stenosis presents with hemiplegia, it may indicate a serious complication such as a stroke.

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The nurse is caring for a 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice. What should be the nurse’s subsequent action?

Correct Answer is B

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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?

Correct Answer is A

Explanation

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