a nurse is assessing a 3 month old infant with suspected pyloric stenosis what clinical manifestation is the nurse likely to observe
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Nursing Elites

HESI LPN

Pediatric HESI 2023

1. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

2. A 2-year-old child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?

Correct answer: B

Rationale: The correct dietary instruction for a 2-year-old child with GERD is to avoid gluten. Gluten is a protein found in wheat, barley, and rye that can worsen GERD symptoms. Avoiding gluten can help reduce inflammation and discomfort in the esophagus. Choices A, C, and D are incorrect because spicy foods, high-fat foods, and dairy products can exacerbate GERD symptoms. Spicy foods can irritate the esophagus, high-fat foods delay stomach emptying leading to increased acid reflux, and dairy products can stimulate acid production, all of which can worsen GERD symptoms.

3. The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What finding would suggest this child has a neuroblastoma?

Correct answer: B

Rationale: Vomiting and poor appetite are common symptoms of neuroblastoma, a malignancy that arises from neural crest cells in the adrenal glands or sympathetic nervous system. This tumor can cause abdominal swelling due to its location and size, leading to symptoms like vomiting and decreased appetite. The presence of a maculopapular rash on the palms (Choice A) is not a typical finding associated with neuroblastoma. Irritability and failure to thrive (Choice C) are nonspecific symptoms that can be seen in various conditions but are not specifically indicative of neuroblastoma. Auscultation revealing wheezing with diminished lung sounds (Choice D) may suggest respiratory conditions rather than neuroblastoma.

4. A 6-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV). What should the nurse include in the care plan?

Correct answer: D

Rationale: Elevating the head of the bed is essential in the care of an infant with RSV as it helps improve breathing by reducing congestion and promoting drainage. This position also aids in maintaining patent airways and can enhance comfort for the infant. Providing small, frequent feedings (Choice A) is generally appropriate for infants but is not a specific intervention for RSV. Administering antibiotics (Choice B) is not indicated for RSV, as it is a viral infection and antibiotics are ineffective against viruses. Maintaining strict isolation (Choice C) is important to prevent the spread of infections, but it is not a direct care intervention for managing RSV symptoms.

5. A nurse is assessing a 10-month-old infant. What developmental milestone should the nurse expect to observe?

Correct answer: D

Rationale: The correct answer is D: Pulling to a stand. By 10 months of age, most infants should be able to pull themselves up to a standing position while holding onto furniture or other support. This milestone indicates good strength and coordination in the lower body. Choice A, Crawling, is typically achieved around 6-9 months of age. Choice B, Sitting without support, usually occurs around 6-8 months. Choice C, Standing with assistance, can typically be seen around 9-12 months, but pulling to a stand is a more advanced milestone expected by 10 months.

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