A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?
Alert and responsive to stimuli
Skin warm and dry and tone is appropriate for ethnicity
Abdomen distended with visible mass noted in right upper quadrant
Full range of motion in extremities, no clicks noted
The Correct Answer is C
Choice A reason: This statement is normal, as an infant who is 2 months old should be alert and responsive to stimuli. The nurse should assess the infant's level of consciousness and responsiveness using the AVPU scale (alert, voice, pain, unresponsive).
Choice B reason: This statement is normal, as an infant who is 2 months old should have warm and dry skin and a tone that is appropriate for their ethnicity. The nurse should assess the infant's skin color, temperature, moisture, and turgor.
Choice C reason: This statement is abnormal, as an infant who is 2 months old should not have a distended abdomen or a visible mass in the right upper quadrant. This could indicate a serious condition such as a liver tumor, a bowel obstruction, or a hernia. The nurse should report this finding to the provider and monitor the infant for signs of pain, vomiting, or jaundice.
Choice D reason: This statement is normal, as an infant who is 2 months old should have full range of motion in their extremities and no clicks noted. The nurse should assess the infant's muscle strength, tone, and symmetry, and check for any signs of hip dysplasia, such as a positive Barlow or Ortolani test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Restricting salt in a child with CF is not advised because these children can lose excessive amounts of salt when they sweat. Maintaining adequate salt intake is important to prevent electrolyte imbalances.
Choice B reason: Limiting fluid intake is not recommended for children with CF. Adequate hydration helps to thin mucus secretions, making them easier to clear from the lungs.
Choice C reason:This is the correct choice. Pancreatic enzyme replacement therapy is essential for children with CF because it helps them digest and absorb nutrients from their food, which is critical due to the malabsorption issues associated with CF.
Choice D reason: Preparing low-fat meals with limited protein is not recommended for children with CF. They require a high-calorie diet with sufficient protein to meet their nutritional needs due to their increased metabolic rate and malabsorption issues.
Correct Answer is C
Explanation
Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.
Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.
Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.
Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.
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