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

Answer and Explanation

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.

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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.

A. Pulmonary stenosis B. Patent ductus arteriosus C. Ventricular septal defect D. Coarctation of the aorta

Correct Answer is B

Explanation

This is because a patent ductus arteriosus is a congenital heart defect that involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. This causes a continuous machinery-like murmur that can be heard on auscultation.

Choice A is wrong because pulmonary stenosis is a narrowing of the pulmonary valve or artery that obstructs blood flow to the lungs. It causes a systolic ejection murmur that is best heard at the upper left sternal border.

Choice C is wrong because the ventricular septal defect is a hole in the wall between the ventricles that allows blood to flow from the left to the right side of the heart. It causes a loud, harsh holosystolic murmur that is best heard at the left lower sternal border.

Choice D is wrong because coarctation of the aorta is a narrowing of the aorta that reduces blood flow to the lower body. It causes a systolic murmur that radiates to the back and weak or absent femoral pulses.

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The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is:.

Correct Answer is A

Explanation

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect?

Correct Answer is B

Explanation

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