A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?
Projectile vomiting after feedings.
Absent bowel sounds.
Increased sodium levels.
Golf ball-sized mass over the left quadrant.
The Correct Answer is A
Choice A rationale
Projectile vomiting after feedings is a classic symptom of pyloric stenosis. This occurs because the enlarged pyloric muscle obstructs the passage of food from the stomach to the small intestine.
Choice B rationale
Absent bowel sounds are not typically associated with pyloric stenosis. While this condition affects the gastrointestinal tract, it does not typically cause a complete absence of bowel sounds.
Choice C rationale
Increased sodium levels are not a typical finding in a newborn with pyloric stenosis. In fact, these infants may have low sodium levels due to vomiting.
Choice D rationale
A golf ball-sized mass over the left quadrant is not a typical finding in a newborn with pyloric stenosis. The classic physical examination finding in pyloric stenosis is a palpable “olive-like” mass in the right upper quadrant of the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Documenting the findings and continuing to monitor the client is appropriate because the nurse has already observed that the fundus is midline and firm, which indicates good uterine tone. The presence of lochia rubra and small clots is expected in the immediate postpartum period.
Choice B rationale: Encouraging the client to empty her bladder can help maintain uterine tone, but in this scenario, the fundus is already firm and midline, so this is not the priority action.
Choice C rationale: Notifying the client's provider is unnecessary at this time because the findings are within normal postpartum expectations and the uterus is firm.
Choice D rationale: Increasing the frequency of fundal massage is not needed because the uterus is already firm and midline, indicating that it is contracting properly.
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