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 placing a toy in the child’s hands might distract the child during the assessment, it does not actively involve the child in the process or help them understand what is happening.
Choice B rationale
Allowing the child to use a stethoscope on a stuffed animal can help the child understand what is happening and feel more comfortable with the procedure. This technique is often used to ensure the cooperation of a preschooler during an assessment of lung sounds.
Choice C rationale
Offering the child bubbles before the stethoscope is placed might distract the child, but it does not directly involve them in the procedure or help them understand what is happening.
Choice D rationale
Having the child blow a cotton ball and having the parent catch it might distract the child, but it does not directly involve them in the procedure or help them understand what is happening.

A. Enalapril B. Digoxin C. Furosemide D. Hydralazine

Correct Answer is B

Explanation

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

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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 is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child’s cooperation?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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