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. Shingles: This is a viral infection caused by the varicella-zoster virus, which also causes chickenpox. It typically manifests as a painful rash that develops into fluid-filled blisters.
B. Athlete's foot: This is a fungal infection of the skin on the feet, particularly between the toes. It causes itching, burning, and cracked, flaking skin.
C. Fever blister: Also known as a cold sore, this is a viral infection caused by the herpes simplex virus. It typically appears as a cluster of small, fluid-filled blisters on or around the lips.
D. Pinworms: This is a parasitic infection caused by tiny, white worms that infect the intestines. It commonly causes anal itching, particularly at night, due to the female worms laying eggs around the anal area.
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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