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 C
Explanation
A. A period of play in the playroom:
Incorrect: While play is generally therapeutic, simply engaging in general play may not directly address the child's distress related to the insulin injection.
B. A video game:
Incorrect: Playing a video game might serve as a distraction, but it may not specifically help the child cope with the distress of the injection in the way that hands-on play with a needleless syringe and a doll can.
C. A needleless syringe and a doll:
Correct Answer: Correct.
Explanation: Allowing the child to play with a needleless syringe and a doll provides a hands-on, interactive experience that can help the child become more familiar and comfortable with the idea of injections. This play activity allows the child to express and understand their feelings in a safe and controlled environment.
D. A story book about a child who has diabetes:
Incorrect: While a storybook can be educational and provide information, it may not directly address the child's immediate distress after an insulin injection. The hands-on play with a needleless syringe and a doll is more focused on the specific experience of receiving injections
Correct Answer is C
Explanation
A. "The immunization schedule will need to be altered."
Incorrect: This is too vague and does not provide specific information about the child's immunization schedule.
B. "The child will receive all of the immunizations except for the polio series."
Incorrect: There is no indication that the child should not receive the polio vaccine. Children with cystic fibrosis are generally recommended to receive all appropriate vaccinations.
C. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
Correct Answer: Children with cystic fibrosis should receive the recommended basic series of immunizations, including vaccines for diseases such as diphtheria, pertussis, tetanus, measles, mumps, rubella, polio, Haemophilus influenzae type b (Hib), hepatitis B, and others. Additionally, they should receive a yearly influenza vaccination to help prevent respiratory complications.
D. "The child should not receive any hepatitis vaccines."
Incorrect: There is no general contraindication for children with cystic fibrosis to receive hepatitis vaccines. The nurse should recommend the appropriate vaccines, including those for hepatitis B, as per the standard immunization schedule.
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