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 D

Explanation

The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.

A. Cross the arms and legs. B. Perform a log roll. C. Raise the hips. D. Flex the knees.

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.

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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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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?