The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings.
Which additional finding should the nurse expect to assess?
Rebound tenderness in the left lower abdominal quadrant.
Stool that consists of mucus and blood.
Olive-size mass in the epigastric area.
Frequent burping accompanied by poor feeding.
The Correct Answer is C
In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the flow of food into the small intestine becomes thickened and narrowed.
Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When moving an adolescent with scoliosis who is recovering after a surgical spinal instrumentation, the nurse should use the log roll technique. This technique involves keeping the spine in alignment while turning the client onto their side. Crossing the arms and legs, raising the hips, and flexing the knees are not appropriate techniques for moving a client with spinal instrumentation.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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