A nurse is caring for a 6-week-old infant who has hypertrophic pyloric stenosis (HPS). Which of the following clinical manifestations should the nurse expect?
Ridged abdomen
Distended neck veins
Red currant jelly stools
Projectile vomiting
The Correct Answer is D
A. Rigid abdomen: A rigid abdomen is not a common finding in HPS. However, it is more typical in conditions such as intestinal obstruction.
B. Distended neck veins: Distended neck veins are not a typical manifestation of HPS. They may be associated with other cardiovascular or respiratory issues.
C. Red currant jelly stools: Red currant jelly-like stools are not typically seen in HPS. This description is often used to describe the appearance of stools in intussusception, which is a different gastrointestinal condition.
D. Projectile vomiting.
Hypertrophic pyloric stenosis is a condition in infants where the muscle at the outlet of the stomach (pylorus) becomes thickened and obstructs the passage of food from the stomach into the small intestine. Projectile vomiting is a characteristic symptom of HPS. The vomit is forceful and seems to shoot out of the infant's mouth, typically occurring after feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Monitoring level of consciousness (LOC): Monitoring the child's level of consciousness is essential as changes in LOC can be an important indicator of the progression of meningitis.
B. Administration of IV antibiotics: Antibiotics are a critical component of the treatment for bacterial meningitis. Early administration of appropriate antibiotics is crucial to control the infection.
C. Decreasing environmental stimuli: Reducing environmental stimuli, such as noise and light, can help minimize discomfort and agitation in a child with meningitis.
D. Increasing IV fluids above maintenance is not typically part of the standard management of bacterial meningitis. Maintaining hydration and electrolyte balance is important, but increasing fluids significantly above maintenance may not be necessary and should be determined based on the child's clinical condition.
E. Instituting droplet precautions: Bacterial meningitis is contagious, and it is important to isolate the child and implement appropriate infection control measures, including droplet precautions, to prevent the spread of the infection to others.
Correct Answer is C
Explanation
In transposition of the great vessels (TGV), the aorta and the pulmonary artery are switched, causing oxygen-rich blood to be pumped back to the lungs and oxygen-poor blood to be pumped out to the body. The ductus arteriosus, a fetal blood vessel that normally closes shortly after birth, allows blood to mix between the two circulations.
Prostaglandin E1 is used to keep the ductus arteriosus open, allowing for a controlled mixing of oxygenated and deoxygenated blood, which can improve oxygen delivery to the body in cases of TGV. This helps maintain oxygenation until corrective surgical interventions can be performed.
The other options, A (decrease pulmonary congestion), B (stimulate the production of red blood cells), and D (increase blood flow to the system), do not accurately describe the primary purpose of Prostaglandin E1 in the context of TGV. The main goal is to maintain a pathway for oxygenated blood to mix with deoxygenated blood to improve oxygen delivery to the body.
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