A nurse is caring for a 1-month-old infant who has a palpable abdominal mass in the right upper quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?

Tracheoesophageal fistula

Hypertrophic pyloric stenosis

Intussusception

Inguinal hernia

Answer and Explanation

The Correct Answer is C

A.   Tracheoesophageal fistula is a congenital anomaly that affects the esophagus and is not associated with abdominal masses or blood and mucus in the stool.
B.   Hypertrophic pyloric stenosis typically causes projectile vomiting and failure to thrive, but it does not typically present with an abdominal mass or blood in the stool.
C.   Intussusception occurs when part of the intestine telescopes into another part, causing a mass, abdominal pain, and sometimes blood and mucus in the stools, which is consistent with the signs described.
D.   Inguinal hernia is a protrusion of abdominal contents into the groin area, not typically associated with abdominal masses in the upper quadrant or blood in the stool.

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Correct Answer is C

Explanation

A. Distended neck veins are typically seen in cases of heart failure or other circulatory issues, not pyloric stenosis.
B. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
C. Weight loss is a common manifestation of pyloric stenosis due to vomiting and poor nutrient intake. This occurs as the narrowing of the pylorus obstructs the passage of food.
D. Occasional vomiting could be a sign of pyloric stenosis, but the hallmark feature is projectile vomiting, which occurs more frequently and is often more forceful.

A. Perform vibration during the client's inspirations. B. Percuss each lung segment for 15 min. C. Administer albuterol prior to CPT. D. Perform CPT immediately after the child eats.

Correct Answer is C

Explanation

A. Vibration is typically performed during exhalation, not inspiration. This helps to loosen secretions.
B. Percussion should not last 15 minutes per lung segment; it is generally performed for shorter periods to avoid discomfort or injury.
C. Administering albuterol prior to CPT helps open the airways, making it easier for the child to expectorate secretions. This is a standard practice for improving the effectiveness of CPT.
D. It is not recommended to perform CPT immediately after a meal, as it may increase the risk of aspiration or discomfort. It is usually advised to wait at least 30 minutes after eating.

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A nurse is caring for a 1-month-old infant who has a palpable abdominal mass in the right upper quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?

Nursing Test Bank

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