The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
Coffee-ground emesis.
Frequent pauses.
Projectile vomiting.
Arched back.
The Correct Answer is C
Choice A reason: Coffee-ground emesis is not the development that the nurse should monitor for. This is a sign of bleeding in the upper gastrointestinal tract, which can be caused by ulcers, gastritis, or esophageal varices. It is not related to the infant's condition, which is likely pyloric stenosis, a narrowing of the opening between the stomach and the small intestine.
Choice B reason: Frequent pauses are not the development that the nurse should monitor for. This is a normal behavior for infants during feeding, as they need to take breaks to breathe and swallow. It is not indicative of any problem or complication.
Choice C reason: Projectile vomiting is the development that the nurse should monitor for. This is a common symptom of pyloric stenosis, a condition that affects about 3 out of 1,000 infants. It occurs when the muscle at the end of the stomach becomes thickened and blocks the passage of food into the small intestine. This causes the infant to vomit forcefully after feeding, leading to dehydration, hunger, and weight loss. The olive-like mass in the upper right abdomen is the enlarged pylorus muscle that can be felt through the skin.
Choice D reason: Arched back is not the development that the nurse should monitor for. This is a sign of pain or discomfort in infants, which can have various causes, such as colic, reflux, or ear infection. It is not specific to pyloric stenosis, although the infant may arch their back due to the abdominal pain caused by the condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Showing indifference to verbal stimulation is not a specific sign of ASD. Some children may have hearing problems, language delays, or other developmental issues that affect their response to verbal cues. However, the nurse should still assess the child's hearing and language skills and refer them to a specialist if needed.
Choice B reason: Having a history of temper tantrums is not a specific sign of ASD. Many children have tantrums as a normal part of their emotional development, especially when they are frustrated, tired, or hungry. However, the nurse should still evaluate the frequency, intensity, and duration of the tantrums and provide guidance to the parents on how to manage them.
Choice C reason: Stroking the hair of a handheld doll is not a specific sign of ASD. This behavior may indicate that the child has a preference for tactile stimulation, which is common among children. It may also show that the child has an attachment to the doll, which is a positive sign of social development.
Choice D reason: Performing odd repetitive behaviors is a specific sign of ASD. These behaviors may include rocking, spinning, hand flapping, lining up objects, or repeating words or sounds. These behaviors are often used by children with ASD to cope with sensory overload, anxiety, or boredom. They may also interfere with the child's learning and social interaction. The nurse should request a follow-up for a possible ASD diagnosis and provide support to the child and the parents.
Correct Answer is A
Explanation
Choice A reason: Arrested growth is a common outcome of renal osteodystrophy in children. It is caused by the impaired bone formation and mineralization that result from the abnormal calcium, phosphorus, vitamin D, and parathyroid hormone levels in chronic kidney disease. Arrested growth can lead to short stature, delayed puberty, and poor quality of life.
Choice B reason: Weight gain is not a specific outcome of renal osteodystrophy in children. It may be related to other factors, such as fluid retention, decreased physical activity, or increased appetite due to medications or hormonal imbalances. Weight gain can worsen the kidney function and increase the risk of cardiovascular complications.
Choice C reason: Low blood pressure is not a specific outcome of renal osteodystrophy in children. It may be caused by other factors, such as dehydration, blood loss, infection, or medications. Low blood pressure can affect the perfusion of vital organs and cause dizziness, fainting, or shock.
Choice D reason: Hypervitaminosis D is not a specific outcome of renal osteodystrophy in children. It may occur as a side effect of vitamin D supplementation, which is often prescribed to treat or prevent renal osteodystrophy. Hypervitaminosis D can cause hypercalcemia, which can lead to nausea, vomiting, constipation, confusion, or kidney stones.
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