A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit.

The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks.

Parents report the vomiting is now forceful and projectile (“like a volcano erupting”) immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry.

The infant has been receiving a cow’s milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks.

The last weight in the pediatrician’s office is 3.54kg (8 lb). No other significant medical or surgical history.

What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client’s progress?

Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits

Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency

Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency

Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions

Answer and Explanation

The Correct Answer is B

Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.

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Correct Answer is A

Explanation

Choice A rationale
Pediculosis capitis, also known as head lice, is a common condition in children. One of the definitive indications of this condition is the presence of firmly attached white particles on the hair, which are the eggs or “nits” of the lice.
Choice B rationale
While itching and scratching of the head can be a symptom of pediculosis capitis, it is not a definitive indication as it can be caused by other conditions such as dandruff or dermatitis.
Choice C rationale
Patchy areas of hair loss are not typically associated with pediculosis capitis. They could indicate a different condition, such as alopecia areata or tinea capitis.
Choice D rationale
Thick yellow-crusted lesions on a red base are not a symptom of pediculosis capitis. This description is more consistent with impetigo, a bacterial skin infection.

A. Bradycardia B. Hyperactive bowel sounds C. WBC 17,000/mm D. Left lower quadrant abdominal pain

Correct Answer is C

Explanation

Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body’s response to inflammation and infection.
Choice B rationale
Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process.
Choice C rationale
A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis.
Choice D rationale
Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.

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Naxlex Comprehensive Predictor Exams

A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?

Correct Answer is A

Explanation

A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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