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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Having the client pant during the next contractions helps to prevent premature pushing. Panting, or controlled breathing, reduces the urge to bear down, which can help prevent cervical swelling or tearing until full dilation is achieved.
Choice B rationale: Assisting the client into a comfortable position is important but not the immediate priority. The client should be instructed to use techniques to prevent pushing.
Choice C rationale: Helping the client to the bathroom to void is not appropriate at this stage of labor, as it may increase the risk of complications and is not the immediate priority.
Choice D rationale: Observing the perineum for signs of crowning is crucial. This action helps the nurse determine if the client is indeed ready to push and if the baby is descending properly. It ensures that the timing for pushing is optimal to prevent complications during delivery.
Correct Answer is D
Explanation
Choice A rationale
Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.
Choice B rationale
Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.
Choice C rationale
Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.
Choice D rationale
Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.
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