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","C","D"]
Explanation
A.Reduce exposure to environmental organisms.
Explanation: Minimizing the child's exposure to environmental organisms helps reduce the risk of infections. This includes practices such as maintaining a clean environment and promoting good hygiene.
B. Maintain the child in a semiprivate room.
Explanation: The type of room (semiprivate or private) may not be directly related to infection control. However, maintaining a clean and controlled environment is important.
C.Use strict aseptic technique for all procedures.
Explanation: Strict aseptic technique is crucial to prevent the introduction of pathogens during procedures. This involves maintaining a sterile field and using appropriate infection control measures during medical interventions.
D.Ensure that anyone entering the child's room wears a mask.
Explanation: Wearing a mask helps prevent the spread of respiratory infections, which can be particularly risky for immunocompromised children. It is a measure to protect the child from potential airborne pathogens.
E. Apply firm pressure to a needlestick area for at least 10 minutes.
Explanation: Applying firm pressure to a needlestick area is relevant in the context of preventing bleeding or hematoma formation but is not directly related to infection control.
Correct Answer is D
Explanation
A. Cracked lips:
Incorrect: While red, cracked lips are part of the mucous membrane changes seen in Kawasaki disease, they are not specific to the acute stage. Mucous membrane changes can occur in both the acute and subacute stages.
B. Desquamation of the skin:
Incorrect: Desquamation, or peeling of the skin, is more characteristic of the subacute or convalescent stages of Kawasaki disease, particularly on the fingers and toes.
C. Normal appearance:
Incorrect: In the acute stage, the child with Kawasaki disease typically exhibits signs of illness, including fever and other clinical manifestations. A "normal appearance" would not be expected in the acute stage.
D. Conjunctival hyperemia.
Explanation: Conjunctival hyperemia, or redness of the eyes, is a common clinical manifestation of the acute stage of Kawasaki disease. Other typical signs and symptoms during this stage include fever, mucous membrane changes (such as red, cracked lips), changes in the extremities, rash, and cervical lymphadenopathy.
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