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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.

A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.

C. Hirschsprung's disease is a congenital condition that aﬀects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.

D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.

A. Report the findings immediately to the healthcare provider. B. Obtain a swab of secretions from the penis and urethra. C. Collect a sterile urine sample for culture and sensitivity. D. Provide the adolescent with a urinal for urinary hesitancy.

Correct Answer is A

Explanation

The nurse should report the findings of significant erythema and swelling in the scrotum immediately to the healthcare provider. The adolescent's symptoms may be indicative of testicular torsion, which is a medical emergency and requires prompt treatment to prevent loss of the testicle. Obtaining a swab of secretions from the penis and urethra or collecting a sterile urine sample for culture and sensitivity are not appropriate actions for this presentation. Providing a urinal for urinary hesitancy may be appropriate if the adolescent is experiencing difficulty urinating, but this should not take precedence over reporting the findings to the healthcare provider.

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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?

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Naxlex Comprehensive Predictor Exams

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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?