The nurse who observes projectile vomiting in a newborn suspects?

SCTIMST Staff Nurse - 2015 (Set-A)

Child Health Nursing (Pediatrics)

Easy

Appeared in: SCTIMST Staff Nurse - 2015 (Set-A)

Explanation

Congenital hypertrophic pyloric stenosis is characterized by the thickening (hypertrophy) of the circular muscle of the pylorus, leading to a narrowing of the pyloric canal.
This creates a gastric outlet obstruction. As the stomach tries to empty its contents against this near-complete blockage, strong peristaltic waves build up pressure, resulting in forceful, projectile vomiting.
The vomit is typically non-bilious (contains no bile) because the obstruction is located before the duodenum, where bile enters the gastrointestinal tract.
This classic presentation of non-bilious projectile vomiting in an infant a few weeks old is the hallmark of pyloric stenosis.

Option A: Tracheo-oesophageal fistula (TEF) is an abnormal connection between the esophagus and the trachea. It presents with choking, coughing, cyanosis, and frothy saliva, especially during feeding, not projectile vomiting.
Option B: Hirschsprung's disease is a motor disorder of the gut caused by the absence of ganglion cells in the distal colon. This leads to a functional obstruction, presenting with failure to pass meconium, abdominal distension, and bilious (bile-stained) vomiting.
Option D: Congenital heart disease (CHD) primarily presents with signs of cardiac and respiratory compromise, such as cyanosis, tachypnea, difficulty feeding, and poor weight gain. While vomiting can occur due to feeding intolerance, it is not the characteristic projectile vomiting seen in pyloric stenosis.

Clinical Relevance

Nursing practice connection: Knowing Differential diagnosis of vomiting in a newborn helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
A nurse's accurate assessment of the type and character of vomiting is crucial for early diagnosis. Differentiating between bilious and non-bilious vomit is a key nursing responsibility, as bilious vomiting often signals a surgical emergency like malrotation.
Nurses play a vital role in managing the infant's fluid and electrolyte status before surgery, which is critical for a safe surgical outcome. Correcting the metabolic alkalosis is a priority.
Post-operative nursing care, including careful reintroduction of feeds and monitoring for complications, is essential for the infant's recovery.

How to Approach the Question

First, identify the key clinical sign in the question stem: 'projectile vomiting' in a 'newborn'.
Consider the pathophysiology of each option and how it would manifest.
Analyze the character of the vomiting. 'Projectile' implies a forceful obstruction.
Differentiate between upper and lower GI obstructions. Upper obstructions (like pyloric stenosis) cause non-bilious vomiting, while lower obstructions (like Hirschsprung's) cause bilious vomiting.
Evaluate the primary symptoms of the other conditions. TEF presents with choking/aspiration, and CHD presents with cardiorespiratory signs.
Select the option whose hallmark sign directly matches the 'projectile vomiting' described in the question.

Concept Tested & Keywords

Concept Tested: Differential diagnosis of vomiting in a newborn.
Stem keywords: projectile vomiting, newborn
Lead-in keywords: suspects
Clinical cues: The specific nature of the vomiting ('projectile') is the key clinical clue that points to a specific diagnosis over other causes of emesis.

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E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 1062-1064

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 173-175