The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?

whitish vesicles located across the chest

Small blue-white spots with a red base found on the buccal mucosa

Pinpoint petechiae noted on both legs

Petechiae spots that are reddish and pinpoint on the soft palate

Answer and Explanation

The Correct Answer is B

A. Whitish vesicles located across the chest:
Incorrect: This description does not match the characteristic appearance or location of Koplik's spots in measles.
B. Small blue-white spots with a red base found on the buccal mucosa:
Correct Answer: Koplik's spots are small, blue-white spots with a red base that typically appear on the buccal mucosa (inner lining of the cheeks). These spots are characteristic of measles and are considered a diagnostic feature.
C. Pinpoint petechiae noted on both legs:
Incorrect: Petechiae are small, reddish-purple spots that result from bleeding under the skin. They are not characteristic of Koplik's spots in measles.
D. Petechiae spots that are reddish and pinpoint on the soft palate:
Incorrect: While petechiae can occur in various conditions, they are not characteristic of Koplik's spots in measles. Koplik's spots specifically manifest as small blue-white spots on the buccal mucosa.

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Correct Answer is D

Explanation

A. Sausage-shaped mass palpated in the upper right abdominal quadrant.
Explanation: A sausage-shaped mass in the upper right abdominal quadrant is more indicative of Hirschsprung's disease, not imperforate anus. In Hirschsprung's disease, there is a lack of ganglion cells in the rectum, leading to obstruction and a palpable mass.
B. The passage of currant jelly-like stools.
Explanation: The passage of currant jelly-like stools is characteristic of intussusception, a condition where one portion of the intestine telescopes into another. It is not associated with imperforate anus.
C. Bile-stained fecal emesis.
Explanation: Bile-stained fecal emesis suggests a possible intestinal obstruction or other gastrointestinal issue, but it is not a specific manifestation of imperforate anus. Imperforate anus is primarily characterized by the absence of a normal anal opening.
D. Failure to pass meconium stool in the first 24 hours after birth.
Explanation:
Imperforate anus refers to a congenital condition in which the opening to the anus is absent or improperly formed. One of the clinical manifestations is the failure to pass meconium stool within the first 24 hours after birth. Meconium is the thick, sticky, greenish-black substance that constitutes a newborn's first stools. The absence of meconium passage suggests a potential obstruction.

A. Ribbon-like stools B. Profuse projectile vomiting C. Bright red blood and mucus in the stools D. Watery diarrhea

Correct Answer is C

Explanation

A. Ribbon-like stools
Explanation: Ribbon-like or pencil-thin stools are associated with conditions affecting the rectum, such as colorectal cancer, but they are not a typical sign of intussusception.
B. Profuse projectile vomiting
Explanation: Profuse projectile vomiting is not a typical sign of intussusception. Vomiting may occur, but it is not the primary characteristic feature.
C. Bright red blood and mucus in the stools
Explanation:
Intussusception is a condition in which one part of the intestine slides into another, causing a blockage. One of the classic signs of intussusception is the presence of "currant jelly" stools, which are characterized by a mixture of bright red blood and mucus in the stools. This occurs due to the compression of the blood vessels in the intestine, leading to bleeding and mucosal discharge.
D. Watery diarrhea
Explanation: Watery diarrhea is not a typical sign of intussusception. The condition is more commonly associated with abdominal pain, vomiting, and the characteristic "currant jelly" stools.

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The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Correct Answer is D

Explanation

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Correct Answer is C

Explanation

The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?

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