The nurse is evaluating an infant’s tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding?

Correct Answer: D

Rationale: The correct answer is D. Emesis after two feedings indicates that the infant is not tolerating the feedings well, which could be a sign of complications post-pyloromyotomy such as gastric outlet obstruction or poor stomach emptying. This warrants immediate attention to prevent further issues. A: Need for frequent burping is a common need for infants and does not necessarily indicate intolerance to feedings. B: Irritability during feeding could be due to various reasons such as hunger, discomfort, or gas, but it does not specifically indicate feeding intolerance. C: The passing of gas is a normal physiological process and does not directly indicate feeding intolerance. In summary, emesis after feedings is concerning as it suggests possible complications, while the other options are more commonly seen in infants and do not directly indicate feeding intolerance.

Correct Answer: A

Rationale: The correct answer is A: A push-and-pull toy. At 18-24 months, children are developing gross motor skills. Push-and-pull toys help strengthen muscles and improve coordination. They also encourage balance and enhance spatial awareness. Nesting blocks are more suitable for fine motor skills, while a bicycle with training wheels requires more advanced motor skills. A computer is not developmentally appropriate as young children need hands-on, physical play for optimal growth and learning.

Correct Answer: B

Rationale: The correct answer is B: Peripheral hypoxia. Clubbing of fingers is commonly seen in conditions with chronic hypoxia, such as tetralogy of Fallot. The lack of oxygen in the blood causes changes in the blood vessels leading to clubbing. Anemia (choice A) may cause tissue hypoxia but is not directly related to clubbing. Delayed physical growth (choice C) is not a known cause of clubbing. Destruction of bone marrow (choice D) is unrelated to clubbing.

Correct Answer: B

Rationale: The correct answer is B: Congestive heart failure. A cardiac defect causing left-to-right shunting leads to increased blood volume in the right side of the heart, causing volume overload and eventually congestive heart failure. Cyanosis (choice A) occurs with right-to-left shunting, not left-to-right shunting. Decreased pulmonary blood flow (choice C) would be more likely with a defect causing right-to-left shunting. Bounding pulses in upper extremities (choice D) are not directly related to left-to-right shunting but can be seen in conditions like aortic regurgitation.

Correct Answer: A

Rationale: The correct answer is A because Kawasaki disease is characterized by high fever, irritability, and mucous membrane changes. The child's irritability can make nursing care challenging due to difficulties in assessing and managing their symptoms and needs effectively. The other choices are incorrect because: B - Kawasaki disease has an unpredictable course with potential complications; C - Antibiotics are not the primary treatment for Kawasaki disease; D - Requests for food are not typically a significant challenge in caring for a child with this condition. In summary, the correct answer highlights the primary symptom that can complicate nursing care, while the other choices are not directly related to the challenges of managing Kawasaki disease.