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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allowing siblings to visit the client in the hospital
- Allowing siblings to visit the client in the hospital is a compassionate gesture and promotes family-centered care. However, it may not directly address the concept of atraumatic care, which focuses on minimizing physical and psychological stress related to healthcare procedures.
B. Using a doll to demonstrate an invasive procedure
- Using a doll to demonstrate an invasive procedure is an example of atraumatic care. It allows the nurse to provide preparatory information to the child in a non-threatening and understandable manner. By visually demonstrating the procedure on a doll, the child can better understand what will happen, reducing anxiety and fear.
C. Encouraging communication between the parents and nurse
- Encouraging communication between the parents and nurse is important for providing holistic care and addressing the child's needs. While effective communication is essential, it may not directly demonstrate the concept of atraumatic care unless it involves discussing how to minimize stress and anxiety during procedures.
D. Arranging the room to accommodate religious practices
- Arranging the room to accommodate religious practices is a form of patient-centered care and respects the cultural and religious beliefs of the patient and family. While important for overall comfort and respect for the patient's values, it may not directly relate to the concept of atraumatic care, which specifically focuses on reducing stress and anxiety during healthcare procedures.
Correct Answer is B
Explanation
A. "I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me."
This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it.
B. "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."
This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns.
C. "I will discuss your child's loss of bladder control with the provider."
This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance.
D. "Why is she wetting the bed in the hospital? She must wet the bed at home."
This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.
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