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?
Sausage-shaped mass palpated in the upper right abdominal quadrant
The passage of currant jelly-like stools
Bile-stained fecal emesis
Failure to pass meconium stool in the first 24 hours after birth
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.
Correct Answer is ["260"]
Explanation
To calculate the total fluid intake, add the volumes of each item consumed:
Juice: ½ cup
1 cup = 240 mL
½ cup = 240 mL / 2 = 120 mL
Gelatin: 3 oz
1 oz ≈ 30 mL
3 oz = 3 * 30 mL = 90 mL
Ice pop: 1 oz
1 oz ≈ 30 mL
1 oz = 30 mL
Ginger ale: 20 mL
Now, add these values:
120 mL (juice) + 90 mL (gelatin) + 30 mL (ice pop) + 20 mL (ginger ale) = 260 mL
Therefore, the nurse should record 260 mL as the child's fluid intake.
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