HESI RN Med Surg
HESI RN Med Surg ( 40 Questions)
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
Coffee-ground emesis is not the development that the nurse should monitor for. This is a sign of bleeding in the upper gastrointestinal tract, which can be caused by ulcers, gastritis, or esophageal varices. It is not related to the infant's condition, which is likely pyloric stenosis, a narrowing of the opening between the stomach and the small intestine.
Frequent pauses are not the development that the nurse should monitor for. This is a normal behavior for infants during feeding, as they need to take breaks to breathe and swallow. It is not indicative of any problem or complication.
Projectile vomiting is the development that the nurse should monitor for. This is a common symptom of pyloric stenosis, a condition that affects about 3 out of 1,000 infants. It occurs when the muscle at the end of the stomach becomes thickened and blocks the passage of food into the small intestine. This causes the infant to vomit forcefully after feeding, leading to dehydration, hunger, and weight loss. The olive-like mass in the upper right abdomen is the enlarged pylorus muscle that can be felt through the skin.
Arched back is not the development that the nurse should monitor for. This is a sign of pain or discomfort in infants, which can have various causes, such as colic, reflux, or ear infection. It is not specific to pyloric stenosis, although the infant may arch their back due to the abdominal pain caused by the condition. .
Choice A reason: Coffee-ground emesis is not the development that the nurse should monitor for. This is a sign of bleeding in the upper gastrointestinal tract, which can be caused by ulcers, gastritis, or esophageal varices. It is not related to the infant's condition, which is likely pyloric stenosis, a narrowing of the opening between the stomach and the small intestine.
Choice B reason: Frequent pauses are not the development that the nurse should monitor for. This is a normal behavior for infants during feeding, as they need to take breaks to breathe and swallow. It is not indicative of any problem or complication.
Choice C reason: Projectile vomiting is the development that the nurse should monitor for. This is a common symptom of pyloric stenosis, a condition that affects about 3 out of 1,000 infants. It occurs when the muscle at the end of the stomach becomes thickened and blocks the passage of food into the small intestine. This causes the infant to vomit forcefully after feeding, leading to dehydration, hunger, and weight loss. The olive-like mass in the upper right abdomen is the enlarged pylorus muscle that can be felt through the skin.
Choice D reason: Arched back is not the development that the nurse should monitor for. This is a sign of pain or discomfort in infants, which can have various causes, such as colic, reflux, or ear infection. It is not specific to pyloric stenosis, although the infant may arch their back due to the abdominal pain caused by the condition. .