Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
A. Abdominal rigidity and pain on palpation
This is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. They may indicate other conditions such as appendicitis or bowel obstruction.
B. Rounded abdomen and hypoactive bowel sounds
This is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis. They may be seen in other causes of vomiting or abdominal distension.
C. Visible peristalsis and weight loss
These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.
D. Distention of lower abdomen and constipation
This is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis. They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
Visible peristalsis and weight loss. These are symptoms of pyloric stenosis, which is a thickening or narrowing of the pylorus, a muscle in the stomach that blocks food from entering the small intestine. Babies with pyloric stenosis often have forceful vomiting, which may cause dehydration.
Choice A is wrong because abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis.
They may indicate other conditions such as appendicitis or bowel obstruction.
Choice B is wrong because a rounded abdomen and hypoactive bowel sounds are also not specific for pyloric stenosis.
They may be seen in other causes of vomiting or abdominal distension.
Choice D is wrong because distention of the lower abdomen and constipation are not related to pyloric stenosis.
They may be due to other problems such as Hirschsprung’s disease or intestinal atresia. Normal ranges for weight gain in infants depend on their age, sex, and feeding method. Generally, infants should gain about 25 to 35 grams per day in the first 3 months of life.
Similar Questions
The diagnosis of pregnancy is based on which positive signs of pregnancy? (Select all that apply.).
A. Identification of fetal heartbeat.
B. Palpation of fetal outline.
C. Visualization of the fetus.
D. Verification of fetal movement.
E. Positive hCG test.
Choice E is wrong because a positive hCG test is a probable sign of pregnancy, not a positive one. A probable sign of pregnancy is strongly suggestive of pregnancy but could have other causes. A positive hCG test could be caused by medications, tumors, or other conditions that affect the level of hCG in the blood or urine.
Full Explanation
These are all positive signs of pregnancy, which are definitive and can only be explained by the presence of a fetus. A positive sign of pregnancy is fetal movement palpated by the nurse-midwife.
Choice E is wrong because a positive hCG test is a probable sign of pregnancy, not a positive one. A probable sign of pregnancy is strongly suggestive of pregnancy but could have other causes. A positive hCG test could be caused by medications, tumors, or other conditions that affect the level of hCG in the blood or urine.
Some other probable signs of pregnancy are uterine enlargement, Hegar’s sign (softening of the lower uterine segment), Goodell’s sign (softening of the cervix), Chadwick’s sign (bluish discoloration of the cervix), ballottement (rebound of the fetus when tapped by the examiner’s finger), Braxton Hicks contractions (painless, irregular uterine contractions), and positive pregnancy test.
Some other positive signs of pregnancy are identification of fetal heartbeat, visualization of the fetus by ultrasound or x-ray, and verification of fetal movement by an experienced clinician.
Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):.
A. Pitocin.
Pitocin is a medicationused to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
B. Methergine.
Methergine is a medication used to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
C. Terbutaline.
Choice C is wrong because Terbutaline is a medication that relaxes the uterus and is used to stop preterm labor, not PPH.
D. Hemabate.
Choice D is wrong because Hemabate is a brand name for carboprost, which is a prostaglandin that can be used for PPH, but it has more side effects and contraindications than Pitocin or Methergine.
E. Magnesium sulfate.
Choice E is wrong because Magnesium sulfate is a medication that prevents seizures in women with preeclampsia or eclampsia, not PPH.
Full Explanation
Pitocin and Methergine are both medications used to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
Choice C is wrong because Terbutaline is a medication that relaxes the uterus and is used to stop preterm labor, not PPH.
Choice D is wrong because Hemabate is a brand name for carboprost, which is a prostaglandin that can be used for PPH, but it has more side effects and contraindications than Pitocin or Methergine.
Choice E is wrong because Magnesium sulfate is a medication that prevents seizures in women with preeclampsia or eclampsia, not PPH.
PPH may be sudden and result in rapid blood loss.
The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss.
Astute assessment of circulatory status can be done with noninvasive monitoring.
Please match the type of noninvasive assessment that the RN would perform with the appropriate clinical manifestation or body system:.
A. Pulse oximetry.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status
B. Heart sounds.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
C. Arterial pulses
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
D. Skin color, temperature, turgor.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
E. Presence or absence of anxiety.
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock. Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure
Full Explanation
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.
Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.