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 A
Explanation
The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.
Touching the tonsillar pillars to stimulate the gag reflex or asking the child to speak would not provide information about the presence of bleeding.
Assessing for teeth clenching or grinding is not related to this particular observation.
Correct Answer is A
Explanation
The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause
A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.
A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.
Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.
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