Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
22. An infant is admitted for pyloric stenosis. Which symptoms should a nurse expect to find? Select all that apply.
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
22. An infant is admitted for pyloric stenosis. Which symptoms should a nurse expect to find? Select all that apply.
. Metabolic alkalosis.
. Olive-shaped mass palpable in the upper right quadrant of abdomen.
. History of projectile vomiting.
. Bile-stained vomitus.
. Decreased urine specific gravity.
. Small, infrequent stools.
Test-Taking Tip
Focus on the name of the diagnosis to help identify symptoms. If the pyloric muscle is stenosed, expect the infant to have symptoms resulting from stomach contents and with nutrients not able to progress through the digestive system.
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . . .
Answer 1 is correct because the infant with pyloric stenosis experiences metabolic alkalosis as a result of excessive vomiting. Answer 2 is correct because this physical assessment (by inspection) is consistent with pyloric stenosis. Answer 3 is correct because this assessment finding is consistent with pyloric stenosis as a result of the pyloric muscle blocking the outflow of stomach contents. Answer 4 is incorrect because the infant with pyloric stenosis has nonbilious vomiting since the obstruction is above the bile duct. Answer 5 is incorrect because the infant with pyloric stenosis is expected to have some degree of dehydration, which would result in an increase in urine specific gravity. Answer 6 is correct because this assessment finding is consistent with pyloric stenosis as a result of poor intake.