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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Pyloric stenosis is a condition in which the muscle at the outlet of the stomach (the pylorus) becomes thickened and obstructs the passage of food into the small intestine. It usually occurs in infants between 2 and 8 weeks of age, and is more common in males. The main symptoms are projectile vomiting after feeding, dehydration, weight loss, and a palpable olive-shaped mass in the right upper quadrant of the abdomen.

Choice B reason: Gastroesophageal reflux is a condition in which the lower esophageal sphincter fails to close properly, allowing the stomach contents to flow back into the esophagus. It is common in infants, especially those who are bottle-fed, and usually resolves by 12 months of age. The main symptoms are regurgitation, spitting up, irritability, and poor weight gain.

Choice C reason: Celiac disease is a condition in which the immune system reacts to gluten, a protein found in wheat, barley, and rye, and damages the lining of the small intestine. It can affect people of any age, but is usually diagnosed in childhood. The main symptoms are diarrhea, abdominal pain, bloating, weight loss, and failure to thrive.

Choice D reason: Lactose intolerance is a condition in which the body lacks the enzyme lactase, which is needed to digest lactose, a sugar found in milk and dairy products. It can affect people of any age, but is more common in adults and certain ethnic groups. The main symptoms are diarrhea, gas, bloating, and abdominal cramps after consuming lactose-containing foods.

A. I'll keep my baby in an upright position after feedings. B. I should position my baby side lying during sleep. C. My baby's formula can be thickened with oatmeal. D. I'll try to feed my baby formula rather than breast milk.

Correct Answer is A

Explanation

Choice A reason: This is the best option to prevent reflux, as it allows gravity to help keep the stomach contents down. The nurse should advise the parent to keep the baby upright for at least 30 minutes after each feeding.

Choice B reason: Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.

Choice C reason: Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.

Choice D reason: Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.

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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?

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