The nurse is caring for a 5-week-old infant with suspected hypertrophic pyloric stenosis. Which clinical manifestation would indicate this condition?
Bilious vomiting and constipation
Abdominal distention and currant jelly-like stools
Rounded abdomen and hypoactive bowel sounds
Ravenously hungry after vomiting
The Correct Answer is D
Choice A reason:
Bilious vomiting and constipation are not typical manifestations of hypertrophic pyloric stenosis. Bilious vomiting, which is green or yellow, indicates that the vomit contains bile and is usually associated with intestinal obstruction beyond the stomach. Hypertrophic pyloric stenosis typically causes non-bilious, projectile vomiting because the obstruction is at the pylorus, before the bile duct.
Choice B reason:
Abdominal distention and currant jelly-like stools are not indicative of hypertrophic pyloric stenosis. Currant jelly-like stools are a classic sign of intussusception, a different condition where part of the intestine telescopes into itself. While abdominal distention can occur in pyloric stenosis, the presence of currant jelly-like stools points to a different diagnosis.
Choice C reason:
A rounded abdomen and hypoactive bowel sounds can be seen in various gastrointestinal conditions but are not specific to hypertrophic pyloric stenosis. While a rounded abdomen may be present due to gastric distention, hypoactive bowel sounds are not a hallmark of this condition. The primary symptom of pyloric stenosis is projectile vomiting.
Choice D reason:
Ravenously hungry after vomiting is a classic manifestation of hypertrophic pyloric stenosis. Infants with this condition often vomit forcefully after feeding and then appear hungry again because the food does not pass through the pylorus into the intestines. This symptom, along with projectile vomiting, is a key indicator of pyloric stenosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
Jaundice can be an assessment finding in infants with a urinary tract infection (UTI). UTIs can cause systemic symptoms in infants, including jaundice, especially in newborns. This is due to the immature liver function and the body’s response to infection1. Jaundice in the context of a UTI requires prompt medical evaluation and treatment to prevent complications.
Choice B reason:
Failure to gain weight is another possible assessment finding in infants with a UTI. Infants with UTIs may experience poor feeding, irritability, and lethargy, which can contribute to inadequate weight gain2. Monitoring an infant’s growth and development is crucial, and any signs of failure to thrive should prompt further investigation for underlying conditions such as UTIs.
Choice C reason:
Swelling of the face is not typically associated with UTIs in infants. While facial swelling can be a sign of other medical conditions, it is not a common symptom of UTIs. UTIs primarily affect the urinary system and may cause symptoms such as fever, irritability, and poor feeding.
Choice D reason:
Persistent diaper rash can be an assessment finding in infants with a UTI. The presence of a UTI can lead to increased urine output and changes in urine composition, which can irritate the skin and contribute to diaper rash. Persistent or recurrent diaper rash in conjunction with other symptoms may warrant further evaluation for a UTI.
Choice E reason:
Vomiting is a common symptom in infants with UTIs. The infection can cause gastrointestinal symptoms such as vomiting, diarrhea, and poor feeding. These symptoms, along with fever and irritability, are often seen in infants with UTIs and should prompt medical evaluation.
Correct Answer is C
Explanation
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
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