The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

Abdominal rigidity and pain on palpation

Rounded abdomen and hypoactive bowel sounds

Visible peristalsis and weight loss

Distention of lower abdomen and constipation

Answer and Explanation

The Correct Answer is C

Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.

Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.

They may indicate other conditions such as appendicitis or bowel obstruction.

Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.

They may be seen in other causes of vomiting or abdominal distension.

Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.

They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.

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Correct Answer is C

Explanation

Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.

Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.

Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.

Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.

Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.

A. Correction of acidosis B. Adequate hydration. C. Pain management. D. Administration of heparin.

Correct Answer is ["B","C"]

Explanation

The child’s care should include adequate hydration and pain management. The management of an acute event of a vaso-occlusive crisis is the use of potent analgesics (opioids), rehydration with normal saline or Ringer’s lactate, treatment of malaria (whether symptomatic or not) using artemisinin combination therapy, and the use of oxygen via face mask, especially for acute chest syndrome.

Choice A is wrong because correction of acidosis is not a specific intervention for the vaso- occlusive crisis.

Acidosis may occur as a complication of sickle cell disease, but it is not the primary cause of the crisis.

Choice D is wrong because the administration of heparin is not recommended for the vaso-occlusive crisis.

Heparin is an anticoagulant that may increase the risk of bleeding and does not prevent or treat the sickling process.

Normal ranges for hemoglobin are 11.5 to 15.5 g/dl for children after 2 years of age.

Normal ranges for reticulocyte count are 0.5% to 1.5% for adults and 0.5% to 2.5% for children.

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The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

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Naxlex Comprehensive Predictor Exams

A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Correct Answer is C

Explanation

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child’s care should include which intervention? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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