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International College of Health Sciences ICHS OB Pediatrics s
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. 0%
B. Rounded abdomen and hypoactive bowel sounds. 100% Most selected
C. Visible peristalsis and weight loss. 0%
D. Distention of the lower abdomen and constipation. 0%
Answer and Explanation
Choice A:
rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric
stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped
mass in the upper abdomen, and signs of dehydration.
Choice B:
rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric
stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the
stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting.
The infant may appear hungry after vomiting and will continue to feed, leading to weight
loss.
Choice C:
rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible
peristalsis occurs as the infant tries to force the stomach contents through the narrowed
pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D:
,rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric
stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis
primarily affects the upper gastrointestinal tract.
Which intervention should be included in the plan of care for an infant with the nursing
diagnosis of Excess Fluid Volume related to congestive heart failure?
A. Weigh the infant every day on the same scale at the same time. 100% Most selected
B. Notify the physician when weight gain exceeds more than 20 g/day. 0%
C. Put the infant in a car seat to minimize movement. 0%
D. Administer digoxin as ordered by the physician. 0%
Answer and Explanation
Choice A:
rationale:
Weighing the infant every day on the same scale at the same time is crucial in
monitoring excess fluid volume in congestive heart failure. Sudden weight gain can
indicate fluid retention, a common sign of worsening heart failure. Daily weight
monitoring helps in early detection and timely intervention.
Choice B:
rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late
for intervention. Daily weight monitoring is essential to detect trends and intervene
promptly to manage excess fluid volume.
Choice C:
,rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing
excess fluid volume in congestive heart failure. It is essential for safety during
transportation but does not address the nursing diagnosis.
Choice D:
rationale:
Administering digoxin as ordered by the physician is a medical intervention for
congestive heart failure. While important, the nursing diagnosis is related to excess fluid
volume, and the focus should be on nursing interventions such as monitoring daily
weights.
The nurse observes some children in the playroom. Which play situation exhibits the
characteristics of parallel play?
A. Kimberly and Amanda share clay to each make things. 0%
B. Brian playing with his truck next to Kristina playing with her truck. 100% Most selected
C. Adam playing a board game with Kyle, Steven, and Erich. 0%
D. Danielle playing with a music box on her mother's lap. 0%
Answer and Explanation
Choice A:
rationale:
Kimberly and Amanda sharing clay to each make things represents cooperative play,
not parallel play. Cooperative play involves interaction and collaboration between
children, whereas parallel play involves children playing side by side without interacting.
Choice B:
, rationale:
Brian playing with his truck next to Kristina playing with her truck demonstrates parallel
play. In parallel play, children play independently but alongside others, showing interest
in what others are doing but without direct interaction.
Choice C:
rationale:
Adam playing a board game with Kyle, Steven, and Erich represents cooperative play, not
parallel play. Cooperative play involves shared activities and collaboration, while parallel
play involves independent activities in proximity to others.
Choice D:
rationale:
Danielle playing with a music box on her mother's lap is an example of solitary play,
where a child plays alone without regard to others. Solitary play is common in younger
children and is different from parallel play.
A parent asks the nurse why self-monitoring of blood glucose is being recommended for
her child with diabetes. The nurse should base the explanation on what information?
A. It is a less expensive method of testing. 0%
B. It is not as accurate as laboratory testing. 0%
C. Children need to learn to manage their diabetes. 100% Most selected
D. The parents are better able to manage the disease. 0%
Answer and Explanation
Choice A:
rationale:
Self-monitoring of blood glucose is not recommended primarily because it is a less
International College of Health Sciences ICHS OB Pediatrics s
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. 0%
B. Rounded abdomen and hypoactive bowel sounds. 100% Most selected
C. Visible peristalsis and weight loss. 0%
D. Distention of the lower abdomen and constipation. 0%
Answer and Explanation
Choice A:
rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric
stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped
mass in the upper abdomen, and signs of dehydration.
Choice B:
rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric
stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the
stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting.
The infant may appear hungry after vomiting and will continue to feed, leading to weight
loss.
Choice C:
rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible
peristalsis occurs as the infant tries to force the stomach contents through the narrowed
pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D:
,rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric
stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis
primarily affects the upper gastrointestinal tract.
Which intervention should be included in the plan of care for an infant with the nursing
diagnosis of Excess Fluid Volume related to congestive heart failure?
A. Weigh the infant every day on the same scale at the same time. 100% Most selected
B. Notify the physician when weight gain exceeds more than 20 g/day. 0%
C. Put the infant in a car seat to minimize movement. 0%
D. Administer digoxin as ordered by the physician. 0%
Answer and Explanation
Choice A:
rationale:
Weighing the infant every day on the same scale at the same time is crucial in
monitoring excess fluid volume in congestive heart failure. Sudden weight gain can
indicate fluid retention, a common sign of worsening heart failure. Daily weight
monitoring helps in early detection and timely intervention.
Choice B:
rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late
for intervention. Daily weight monitoring is essential to detect trends and intervene
promptly to manage excess fluid volume.
Choice C:
,rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing
excess fluid volume in congestive heart failure. It is essential for safety during
transportation but does not address the nursing diagnosis.
Choice D:
rationale:
Administering digoxin as ordered by the physician is a medical intervention for
congestive heart failure. While important, the nursing diagnosis is related to excess fluid
volume, and the focus should be on nursing interventions such as monitoring daily
weights.
The nurse observes some children in the playroom. Which play situation exhibits the
characteristics of parallel play?
A. Kimberly and Amanda share clay to each make things. 0%
B. Brian playing with his truck next to Kristina playing with her truck. 100% Most selected
C. Adam playing a board game with Kyle, Steven, and Erich. 0%
D. Danielle playing with a music box on her mother's lap. 0%
Answer and Explanation
Choice A:
rationale:
Kimberly and Amanda sharing clay to each make things represents cooperative play,
not parallel play. Cooperative play involves interaction and collaboration between
children, whereas parallel play involves children playing side by side without interacting.
Choice B:
, rationale:
Brian playing with his truck next to Kristina playing with her truck demonstrates parallel
play. In parallel play, children play independently but alongside others, showing interest
in what others are doing but without direct interaction.
Choice C:
rationale:
Adam playing a board game with Kyle, Steven, and Erich represents cooperative play, not
parallel play. Cooperative play involves shared activities and collaboration, while parallel
play involves independent activities in proximity to others.
Choice D:
rationale:
Danielle playing with a music box on her mother's lap is an example of solitary play,
where a child plays alone without regard to others. Solitary play is common in younger
children and is different from parallel play.
A parent asks the nurse why self-monitoring of blood glucose is being recommended for
her child with diabetes. The nurse should base the explanation on what information?
A. It is a less expensive method of testing. 0%
B. It is not as accurate as laboratory testing. 0%
C. Children need to learn to manage their diabetes. 100% Most selected
D. The parents are better able to manage the disease. 0%
Answer and Explanation
Choice A:
rationale:
Self-monitoring of blood glucose is not recommended primarily because it is a less
