A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect?
Distended neck veins
Ridged abdomen
Projectile vomiting
Red currant jelly stools
The Correct Answer is C
Rationale:
A. Distended neck veins are not associated with pyloric stenosis.
B. A ridged abdomen is not typical of pyloric stenosis; rather, an olive-shaped mass may be palpated in the right upper quadrant.
C. Projectile vomiting is a hallmark sign of pyloric stenosis due to the obstruction at the pylorus, preventing food from passing into the small intestine.
D. Red currant jelly stools are associated with intussusception, not pyloric stenosis.
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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Sitting the child upright and forward while applying pressure to the sides of the nose is the correct approach to managing a nosebleed. This position prevents blood from flowing down the throat and helps stop the bleeding by applying direct pressure.
B. Turning the child's head to the side and pressing on the nasal ridge is incorrect because it does not effectively control the bleeding and may cause blood to flow into the throat.
C. Lying the child in bed and pressing on the forehead is not effective in controlling a nosebleed.
D. Lying flat and applying pressure to the cheeks does not address the source of the bleeding and may worsen the situation.
Correct Answer is B
Explanation
Rationale:
A. Deep, rapid respirations, known as Kussmaul respirations, are typically associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Tachycardia is a common symptom of hypoglycemia, as the body releases adrenaline in response to low blood glucose levels, leading to an increased heart rate.
C. Polyuria is associated with hyperglycemia, not hypoglycemia.
D. Dry, flushed skin is typically a sign of dehydration or hyperglycemia, not hypoglycemia.