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 C
Explanation
Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.
Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.
Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.
Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.
Correct Answer is D
Explanation
This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.
Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.
Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.
Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.
Normal ranges for respiratory rate in premature infants are 40 to 60 breaths per minute. Normal ranges for oxygen saturation in premature infants are 88% to 92%.
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