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A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?

A.

Projectile vomiting after feedings

B.

Absent bowel sounds

C.

Increased sodium level

D.

Golf ball-size mass over the left quadrant

Answer and Explanation

The Correct Answer is A

A. Projectile vomiting after feedings: Projectile vomiting after feedings, especially occurring a short time after feeding, is a classic sign of pyloric stenosis due to obstruction at the pylorus.
B. Absent bowel sounds: Absent bowel sounds may occur in more advanced cases of bowel obstruction but are not specific to pyloric stenosis.
C. Increased sodium level: Increased sodium level is not typically associated with pyloric stenosis.
D. Golf ball-size mass over the left quadrant: A palpable mass in the left quadrant is not a typical finding in pyloric stenosis.


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Related Questions

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

    Immediate priority: The child is febrile (38.9°C) with tachycardia. Fever and low Hgb and platelets suggest possible serious underlying hematologic disorder (e.g., leukemia, bone marrow suppression). Infection is life-threatening in this context. So temperature (fever) should be addressed first. Next concern: The lab values (low Hgb, Hct, platelets) show significant hematologic abnormalities that explain the fatigue, bruising, and petechiae and will guide further treatment (possible transfusion, infection risk management). Incorrect answers:
  • Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
  • Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
  • Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.
  • Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.
  • Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.
  • Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

    • Correct Answer is B

    Explanation

    A. Dry mucous membranes. Associated with dehydration, not hypoglycemia.
    B. Diaphoresis. Sweating (diaphoresis) is a common symptom of hypoglycemia due to the body’s response to low blood glucose levels.
    C. Polyuria. Associated with hyperglycemia, where there is an excess of glucose leading to increased urine output.
    D. Fruity breath odor. Indicates ketosis, which is a sign of hyperglycemia and diabetic ketoacidosis, not hypoglycemia.

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