A nurse is assessing a 6-week-old child for progressive weight loss and projectile vomiting. The nurse suspects pyloric stenosis. What other assessment finding should be expected?

The child accepts a feeding after vomiting

Sausage shaped upper abdominal mass

Jelly- like consistency stools

Severe pain in the abdomen

Answer and Explanation

The Correct Answer is A

A.   Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B.   One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C.   Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D.   While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.

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Correct Answer is []

Explanation

Condition:

Acute Laryngotracheobronchitis (Croup)

The harsh, bark-like cough and hoarse cry are classic symptoms of croup (acute laryngotracheobronchitis), a viral infection that typically affects young children. Mild work of breathing and stridor (a high-pitched sound during inspiration) indicate upper airway narrowing, which is characteristic of croup.

Actions to Take

Prepare to administer IV steroids:

Steroids (e.g., dexamethasone) are used to reduce airway inflammation in croup and are considered first-line treatment. They help reduce the swelling in the upper airways, making breathing easier and improving stridor and cough. IV steroids are often used in more severe cases, such as in an emergency department setting.

Administer racemic epinephrine:

Racemic epinephrine is a bronchodilator used to treat moderate to severe cases of croup. It works by reducing inflammation and relaxing the muscles of the upper airway, which helps relieve stridor and airway obstruction. This medication is typically given via nebulizer in the emergency department to provide rapid relief.

Parameters to Monitor

Oxygen saturation:

It is important to monitor oxygen saturation (SpO2) to assess if the child is getting enough oxygen. Croup can lead to hypoxia if the airway becomes severely narrowed. Monitoring oxygen levels ensures that the child is not deteriorating and allows for appropriate interventions if oxygen levels fall below normal (typically below 92% or 90%, depending on clinical guidelines).

Respiratory rate:

Monitoring the respiratory rate provides insight into how well the child is maintaining adequate ventilation. In cases of croup, increased work of breathing and distress can cause a higher respiratory rate. If the rate becomes very high or very low, it may indicate worsening distress or impending respiratory failure. Regular monitoring helps guide treatment and reassessment.

A. Soft non tender abdomen. B. Normal appearing perineum. C. Meconium leakage via the vagina or urethra. D. Poor sucking reflex.

Correct Answer is C

Explanation

A. A soft, non-tender abdomen would be normal and not suggestive of any specific pathology.
B. A normal appearing perineum would not be expected with an anorectal malformation, which typically presents with a visible defect in the perineum.
C. Meconium leakage via the vagina or urethra is a possible sign of an anorectal malformation. This could occur if there is a fistula connecting the gastrointestinal tract to the urinary or genital tract.
D. Poor sucking reflex is not directly associated with anorectal malformations but may occur in certain other conditions, such as central nervous system issues.

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A nurse is assessing a 6-week-old child for progressive weight loss and projectile vomiting. The nurse suspects pyloric stenosis. What other assessment finding should be expected?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Actions to Take

Parameters to Monitor

A nurse is caring for a female newborn with an apparent anorectal malformation. The nurse should assess the infant for which of the following other potential finding?

Correct Answer is C

Explanation

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