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 A

Explanation

A. Place the child in a side-lying position.

This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs.

B. Restrain the child's arms.

Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure.

C. Elevate the child's legs on a pillow.

Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury.

D. Insert a padded tongue blade into the child's mouth.

Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.

A. No treatment is necessary, the fluid is reabsorbing normally B. Keeping the infant in a flat, supine position until the fluid is gone C. Referral to a surgeon for repair D. Massaging the groin area twice a day until the fluid is gone.

Correct Answer is A

Explanation

A. No treatment is necessary, the fluid is reabsorbing normally:

- This option suggests that the hydrocele is resolving spontaneously, which is often the case in infants. The physician may choose to observe the hydrocele over time as it is likely to resolve without intervention.

B. Keeping the infant in a flat, supine position until the fluid is gone:

- This option does not address the underlying cause of the hydrocele and is not a standard treatment recommendation. Additionally, positioning changes are unlikely to affect the resolution of the hydrocele.

C. Referral to a surgeon for repair:

- Surgical repair may be considered if the hydrocele persists beyond a certain age or if it causes discomfort or complications. However, it is typically not recommended in infants unless the hydrocele persists beyond infancy or causes other issues.

D. Massaging the groin area twice a day until the fluid is gone:

- Massaging the groin area is not a recommended treatment for hydrocele and may not be effective in resolving the condition. Additionally, manipulating the scrotum may cause discomfort or injury to the infant.

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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

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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