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 A
Explanation
Choice A reason: This choice is correct because a child who has nephrotic syndrome is the most appropriate roommate for a child who has leukemia. Nephrotic syndrome is a kidney disorder that causes proteinuria, edema, hypoalbuminemia, and hyperlipidemia. It does not pose any risk of infection or injury to the child who has leukemia, and it does not require any isolation or special precautions. Therefore, placing these two children in the same room can help to conserve resources and promote socialization.
Choice B reason: This choice is incorrect because a child recovering from a ruptured appendix is not an appropriate roommate for a child who has leukemia. A ruptured appendix is a medical emergency that occurs when the appendix becomes inflamed and bursts, releasing bacteria and pus into the abdominal cavity. It may cause peritonitis, sepsis, or abscess formation, and it requires surgery and antibiotics. It may pose a risk of infection to a child who has leukemia, who has a weakened immune system due to chemotherapy or bone marrow suppression. Therefore, placing these two children in the same room can increase the chance of cross-contamination and complications.
Choice C reason: This choice is incorrect because a child who has rheumatic fever is not an appropriate roommate for a child who has leukemia. Rheumatic fever is an inflammatory disease that occurs as a complication of streptococcal infection, such as strep throat or scarlet fever. It may affect the heart, joints, skin, or nervous system, and it requires anti-inflammatory and antibiotic medications. It may pose a risk of infection to the child who has leukemia, who has a compromised immune system due to cancer or treatment. Therefore, placing these two children in the same room can increase the likelihood of transmission and infection.
Choice D reason: This choice is incorrect because a child who has cystic fibrosis is not an appropriate roommate for a child who has leukemia. Cystic fibrosis is a genetic disorder that affects the mucus glands of the lungs, pancreas, liver, intestines, and reproductive organs. It causes thick and sticky mucus to build up in the organs, leading to chronic lung infections, pancreatic insufficiency, malnutrition, and infertility. It requires respiratory therapy, enzyme supplements, nutritional support, and antibiotics. It may pose a risk of infection to the child who has leukemia, who has a reduced ability to fight germs due to malignancy or therapy. Therefore, placing these two children in the same room can increase the possibility of exposure and infection.
Correct Answer is B
Explanation
Choice A: This instruction is not correct, as the child should avoid taking a tub bath for the first 3 days after a cardiac catheterization, which is a procedure that involves inserting a thin tube into a blood vessel and advancing it to the heart to diagnose or treat heart problems. Taking a tub bath can increase the risk of infection or bleeding at the insertion site, which is usually in the groin or arm. The child should take a shower instead and keep the insertion site clean and dry.
Choice B: This instruction is correct, as the child may experience some discomfort or soreness at the insertion site after a cardiac catheterization. Giving the child acetaminophen can help relieve the pain and reduce inflammation. The child should avoid taking aspirin or ibuprofen, as they can increase the risk of bleeding.
Choice C: This instruction is not correct, as the child does not need to stay home for 1 week after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume normal activities within 2 to 3 days after the procedure, as long as they avoid strenuous exercise, heavy lifting, or contact sports.
Choice D: This instruction is not correct, as the child does not need to limit their diet to clear liquids for the first 24 hours after a cardiac catheterization unless there are complications or specific instructions from the provider. The child can resume their regular diet as soon as they feel hungry and drink plenty of fluids to flush out the contrast dye used during the procedure.
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