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. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn?

Correct answer: D

Rationale: In hypospadias, the urethral opening is located along the ventral surface of the penis. This congenital condition results in the urethral meatus opening on the underside of the penis, rather than at the tip. Choice A is incorrect as there is typically a urethral opening present, though in an abnormal location. Choice B is not a characteristic feature of hypospadias. Choice C is incorrect as the urethral opening in hypospadias is not along the dorsal surface but rather along the ventral surface of the penis.

3. A child with a diagnosis of celiac disease is being discharged. What dietary instructions should the nurse provide?

Correct answer: B

Rationale: The correct answer is B: 'Avoid gluten.' Celiac disease is a condition in which the immune system reacts to gluten, a protein found in wheat, barley, and rye. Avoiding gluten is essential in managing celiac disease as it helps prevent damage to the small intestine and alleviate symptoms. Choices A, C, and D are incorrect because dairy products, high-fat foods, and foods high in sugar do not directly relate to the management of celiac disease. It is crucial to focus on eliminating gluten-containing foods to effectively control the condition.

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. An infant is diagnosed with Hirschsprung disease. What nursing intervention is essential before surgery?

Correct answer: D

Rationale: The correct nursing intervention essential before surgery for an infant with Hirschsprung disease is maintaining NPO (nothing by mouth) status. This is important to prevent aspiration during and after the surgical procedure. Administering antibiotics (Choice A) may be necessary in some cases but is not the priority intervention before surgery. Ensuring bowel rest (Choice B) is not directly related to preparing for surgery and may not be the most critical intervention. Performing regular enemas (Choice C) is not recommended before surgery for Hirschsprung disease as it can aggravate the condition.

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