A one-month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. Which other findings should the nurse identify that are consistent with pyloric stenosis?
Rooting, hunger, and irritability.
An olive-shaped mass in the abdominal area.
Bile-stained emesis.
Perianal diaper rash from persistent diarrhea
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Closing the blinds room so is darkened is inappropriate. The lighting in the room is unlikely to have an impact on the seizure or its management. Ensuring safety and maintaining the airway is the priority.
B.Asking the mother to release the child is appropriate. It’s important to ensure the safety of both the child and the mother. The mother should be asked to release the child to prevent any potential harm to the child during the seizure
C. Monitoring the child's airway and tongue is appropriate. During a seizure, there is a risk of the child's airway being compromised. The nurse should closely monitor the child's airway to ensure that it remains open and that the tongue does not obstruct the airway. Positioning the child on their side can also help prevent choking.
D. Administering an anticonvulsant medication is inappropriate. The nurse should not administer medication without a healthcare provider's order. In a seizure emergency, the focus is on maintaining safety and managing the seizure itself.
E. Place pillows inside the side rails: This is a correct action to prevent injury during the seizure. Padding the side rails helps protect the child from hitting their head or limbs on the hard surfaces.
Correct Answer is C
No explanation
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