What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
Projectile vomiting.
Effortless regurgitation.
Metabolic acidosis.
Distended abdomen.
The Correct Answer is A
Choice A rationale
Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine.
Choice B rationale
Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice C rationale
Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice D rationale
While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.
Rationale for each choice:
- Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
- Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
- Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
- Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.
Correct Answer is ["3.125"]
Explanation
The child weighs 22 lb, which is approximately 10 kg (since 1 kg is approximately 2.2 lb).
The prescribed dose of acetaminophen is 10 mg/kg. Step 1 is: Calculate the total dose of acetaminophen for the child. This is done by multiplying the child’s weight in kg by the prescribed dose in mg/kg. 10 kg×10 mg/kg=100 mg The available acetaminophen liquid is 160 mg/5 mL. Step 2 is: Calculate the volume of acetaminophen liquid to administer. This is done by setting up a proportion with the total dose of acetaminophen and the concentration of the available liquid. x mL100 mg=5 mL160 mg Solving for x gives: x=160 mg mg×5 mL=3.125 mL Therefore, the nurse should administer approximately 3.125 mL of the acetaminophen liquid. .
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