The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
Abdominal rigidity and pain on palpation
Rounded abdomen and hypoactive bowel sounds
Visible peristalsis and weight loss
Distention of lower abdomen and constipation
The Correct Answer is C
Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.
Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.
They may indicate other conditions such as appendicitis or bowel obstruction.
Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.
They may be seen in other causes of vomiting or abdominal distension.
Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.
They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","F"]
Explanation
A health history is a holistic assessment of all factors affecting a patient’s health status, including information about social, cultural, familial, and economic aspects of the patient’s life as well as any other component of the patient’s life style that affects health and well-being.
Choice B is wrong because physical assessment is not part of the health history, but a separate process of examining the patient’s body systems.
Choice A is correct because review of systems is a systematic method of collecting data on all body systems.
Choice C is correct because sexual history is an important aspect of the patient’s health that may affect their risk for sexually transmitted infections, reproductive health, and psychosocial well-being.
Choice D is correct because height, weight, BMI data are part of the biographical data that provide a baseline for comparing the patient’s characteristics to established norms for physical and emotional health.
Choice E is correct because diet and nutritional intake are relevant factors that influence the patient’s health status and may indicate potential problems such as malnutrition, obesity, or eating disorders.
Choice F is correct because family medical history provides information about the patient’s genetic risk for certain diseases and conditions that may affect their current or future health.
Correct Answer is A
Explanation
A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.
Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.
Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.
A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.
Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.
Hemorrhages can be caused by diabetes, hypertension, or trauma.
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