A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?

Projectile vomiting

Metabolic acidosis

Effortless regurgitation

Distended abdomen

Answer and Explanation

The Correct Answer is A

A. Projectile vomiting

Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents.

B. Metabolic acidosis

Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly.

C. Effortless regurgitation

Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents.

D. Distended abdomen

A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.

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Correct Answer is C

Explanation

A. Children with Reye syndrome are admitted to the hospital:

This statement is accurate. Children with Reye syndrome often require hospital admission for monitoring and supportive care. Therefore, it does not indicate a need for further education.

B. I will have my children immunized against varicella and influenza:

This statement is also accurate. Vaccination against varicella (chickenpox) and influenza is recommended to prevent these illnesses. It does not indicate a need for further education.

C. I will give aspirin to my child to treat a headache:

This statement is concerning because giving aspirin to a child with Reye syndrome can worsen their condition. Aspirin use is contraindicated in children with viral illnesses due to the risk of Reye syndrome. Therefore, this statement indicates a need for further education.

D. I will make sure not to give my child any products containing aspirin:

This statement is accurate. Avoiding products containing aspirin is essential to prevent the risk of Reye syndrome in children. It does not indicate a need for further education.

A. Maintain seizure precautions. B. Document intake and output. C. Administer antibiotics when available. D. Reduce environmental stimuli.

Correct Answer is C

Explanation

A. Maintain seizure precautions:

While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions.

B. Document intake and output:

Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications.

C. Administer antibiotics when available:

Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death.

D. Reduce environmental stimuli:

While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.

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A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows further education is needed about reye syndrome when a mother states:

Correct Answer is C

Explanation

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Correct Answer is C

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