NCLEX STYLE
A nurse is assessing an infant suspected of having pyloric stenosis. Which finding is most characteristic of this condition?
A. Bilious vomiting
B. Projectile non-bilious vomiting
C. Diarrhea with mucus
D. Abdominal distention with fever
B. Projectile non-bilious vomiting
Rationale:
Pyloric stenosis causes forceful (projectile), non-bilious vomiting due to gastric outlet obstruction. Bile is absent because the obstruction occurs before the duodenum.
A nurse palpates the abdomen of an infant with suspected pyloric stenosis. Which finding should the nurse expect?
A. Enlarged spleen
B. Olive-shaped mass in the right upper quadrant
C. Rebound tenderness in the lower abdomen
D. Diffuse abdominal rigidity
B. Olive-shaped mass in the right upper quadrant
Rationale:
A hallmark finding is a small, firm, olive-shaped mass in the RUQ, representing the hypertrophied pylorus.
A nurse is preparing to administer preoperative care for an infant with pyloric stenosis. What is the priority intervention?
A. Begin oral feedings
B. Administer antibiotics
C. Correct fluid and electrolyte imbalance
D. Position infant prone
C. Correct fluid and electrolyte imbalance
Rationale:
Before surgery (pyloromyotomy), the priority is rehydration and electrolyte correction due to dehydration from vomiting.
After a pyloromyotomy, which finding requires immediate nursing intervention?
A. Small amount of vomiting
B. Abdominal incision redness with drainage
C. Gradual increase in feeding tolerance
D. Mild fussiness
B. Abdominal incision redness with drainage
Rationale:
Signs of infection or surgical complication require immediate attention. Mild vomiting can be expected early post-op.
A nurse is caring for a 1-month-old infant admitted with pyloric stenosis who has had repeated episodes of vomiting. The nurse reviews the laboratory results and provider prescriptions. Which of the following findings and interventions should the nurse recognize as appropriate or expected?
Select all that apply.
A. Metabolic alkalosis with compensatory hypoventilation
B. Initiation of potassium replacement prior to verifying urine output
C. Hypochloremia contributing to impaired gastric acid balance
D. Delaying surgery until fluid and electrolyte imbalances are corrected
E. Bilious emesis indicating worsening of pyloric stenosis
A. Metabolic alkalosis with compensatory hypoventilation
Forceful vomiting causes metabolic alkalosis in attempts to compensate, respiratory hypoventilation occurs resulting in CO₂ retention
C. Hypochloremia contributing to impaired gastric acid balance
D. Delaying surgery until fluid and electrolyte imbalances are corrected... Priority is stabilization (fluids + electrolytes)
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B. Initiation of potassium replacement prior to verifying urine output
✘ Incorrect
E. Bilious emesis indicating worsening of pyloric stenosis Incorrect