A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Distended neck veins
Rigid abdomen
Projectile vomiting
Red currant jelly stools
The Correct Answer is C
Choice A: Distended neck veins are not a clinical manifestation of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Distended neck veins are a sign of increased venous pressure, which can occur in conditions that affect the right side of the heart or cause fluid overload.
Choice B: Rigid abdomen is not a clinical manifestation of pyloric stenosis, but rather a sign of peritonitis, which is inflammation of the peritoneum, which is the membrane that lines the abdominal cavity. Peritonitis can be caused by infection, perforation, or trauma to any abdominal organ. A rigid abdomen indicates severe pain and inflammation in the abdominal cavity.
Choice C: Projectile vomiting is a clinical manifestation of pyloric stenosis, as it indicates forceful expulsion of stomach contents due to obstruction at the pylorus. Projectile vomiting can occur shortly after feeding and may contain undigested milk or formula. Projectile vomiting can cause dehydration, electrolyte imbalance, or weight loss.
Choice D: Red currant jelly stools are not a clinical manifestation of pyloric stenosis, but rather a sign of intussusception, which is a condition that causes telescoping of one segment of bowel into another. Intussusception can cause obstruction and ischemia of the bowel and lead to bleeding and necrosis. Red currant jelly stools indicate blood and mucus in the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This information is incorrect, as the first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not 2 weeks. The DTaP vaccine protects against three serious bacterial diseases that can cause respiratory infections, nerve damage, or death. The DTaP vaccine is given in five doses at 2, 4, 6, 15 to 18 months, and 4 to 6 years of age.
Choice B: This information is correct, as the first dose of the hepatitis B vaccine is usually given within 24 hours of birth or prior to discharge from the hospital. The hepatitis B vaccine protects against a viral infection that can cause liver inflammation, cirrhosis, or cancer. The hepatitis B vaccine is given in three doses at birth, 1 to 2 months, and 6 to 18 months of age.
Choice C: This information is incorrect, as the first dose of the measles, mumps, rubella (MMR) vaccine is usually given at 12 to 15 months of age, not 6 months. The MMR vaccine protects against three viral diseases that can cause fever, rash, swelling of glands, or complications such as pneumonia, encephalitis, or deafness. The MMR vaccine is given in two doses at 12 to 15 months and 4 to 6 years of age.
Choice D: This information is incorrect, as the first dose of the pneumococcal conjugate (PCV13) vaccine is usually given at 2 months of age, not on the first birthday. The PCV13 vaccine protects against a bacterial infection that can cause pneumonia, meningitis, or sepsis. The PCV13 vaccine is given in four doses at 2, 4, 6, and 12 to 15 months of age.
Correct Answer is B
Explanation
Choice A: Skin cancer is a malignant growth of the skin cells, which can be caused by exposure to ultraviolet radiation, genetic mutations, or immunosuppression. Skin cancer does not affect the mouth and does not cause a white, milky plaque. Skin cancer may cause changes in the color, shape, size, or texture of a mole or a skin lesion.
Choice B: Candidiasis or thrush is a fungal infection of the mouth, which can be caused by overgrowth of Candida albicans, a type of yeast that normally lives in the body. Candidiasis or thrush can occur in people who have a weakened immune system, such as those who have a systemic disorder, take antibiotics, immunosuppressants, or corticosteroids, or have a smoking history. Candidiasis or thrush can cause soreness in the mouth and difficulty eating. Candidiasis or thrush can also cause a white, milky plaque that does not come off with rubbing.
Choice C: Squamous cell carcinoma is a type of skin cancer that affects the squamous cells, which are flat cells that form the outer layer of the skin. Squamous cell carcinoma can occur in areas that are exposed to sun damage, such as the face, ears, lips, or neck. Squamous cell carcinoma does not affect the mouth and does not cause a white, milky plaque. Squamous cell carcinoma may cause a red, scaly, crusty, or bleeding bump or patch on the skin.
Choice D: Herpes simplex is a viral infection that affects the skin and mucous membranes, such as the mouth, lips, genitals, or eyes. Herpes simplex is transmitted by direct contact with an infected person or object. Herpes simplex does not cause a white, milky plaque. Herpes simplex may cause painful blisters or ulcers that burst and form scabs.
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