A NICU nurse is completing an assessment on a premature infant male born at 29 weeks gestation. It is noted that the male infant has no palpable testes in the scrotum. The nurse should:

Document this expected finding.

Insert a urinary catheter to collect a urine specimen.

Initiate a social work consult.

Call the provider for this unexpected finding.

Answer and Explanation

The Correct Answer is A

Choice A reason:

In premature infants, it is common for the testes to not be palpable in the scrotum at birth. This condition, known as cryptorchidism, affects about 30% of preterm infants1. The testes usually descend into the scrotum by the time the infant reaches term or within the first few months of life. Therefore, the nurse should document this as an expected finding and continue to monitor the infant’s development.

Choice B reason:

Inserting a urinary catheter to collect a urine specimen is not necessary in this situation. The absence of palpable testes in a premature infant is a common finding and does not indicate a need for immediate urinary evaluation. Urinary catheterization should be reserved for specific medical indications, such as suspected urinary tract infection or urinary retention.

Choice C reason:

Initiating a social work consult is not relevant to the clinical finding of undescended testes in a premature infant. Social work consultations are typically initiated for psychosocial issues, family support, or discharge planning. The absence of palpable testes is a medical finding that should be documented and monitored by the healthcare team.

Choice D reason:

Calling the provider for this unexpected finding is not necessary because the absence of palpable testes in a premature infant is an expected finding. The nurse should document the finding and continue to monitor the infant’s development. If the testes do not descend by the time the infant reaches term or within the first few months of life, further evaluation and management may be needed.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason:

Oral rehydration solution (ORS) is the first-line treatment for children with acute diarrhea and moderate dehydration. ORS contains a precise balance of electrolytes and glucose, which helps to rehydrate the child effectively by promoting the absorption of water and electrolytes in the intestines. The World Health Organization (WHO) and the American Academy of Pediatrics recommend ORS as the preferred treatment for dehydration caused by diarrhea. It is effective, easy to administer, and can be given at home or in a healthcare setting.

Choice B reason:

Antidiarrheal medications such as paregoric are not recommended for children with acute diarrhea. These medications can slow down the movement of the intestines, which may prolong the infection and increase the risk of complications. Additionally, they do not address the underlying cause of dehydration. The primary goal in managing acute diarrhea is to rehydrate the child, which is best achieved with ORS.

Choice C reason:

Clear liquids, such as water, broth, or diluted fruit juices, can be used to provide some hydration, but they do not contain the necessary electrolytes to effectively treat moderate dehydration. Clear liquids alone are not sufficient to replace the lost electrolytes and fluids caused by diarrhea. ORS is specifically formulated to address these needs and is more effective in rehydrating the child.

Choice D reason:

Adsorbents, such as kaolin and pectin, are not recommended for the treatment of acute diarrhea in children. These substances can bind to the contents of the intestines and may reduce the frequency of stools, but they do not address the underlying dehydration. The primary focus should be on rehydration with ORS, which provides the necessary electrolytes and fluids to restore the child’s hydration status.

A. Bilious vomiting and constipation B. Abdominal distention and currant jelly-like stools C. Rounded abdomen and hypoactive bowel sounds D. Ravenously hungry after vomiting

Correct Answer is D

Explanation

Choice A reason:

Bilious vomiting and constipation are not typical manifestations of hypertrophic pyloric stenosis. Bilious vomiting, which is green or yellow, indicates that the vomit contains bile and is usually associated with intestinal obstruction beyond the stomach. Hypertrophic pyloric stenosis typically causes non-bilious, projectile vomiting because the obstruction is at the pylorus, before the bile duct.

Choice B reason:

Abdominal distention and currant jelly-like stools are not indicative of hypertrophic pyloric stenosis. Currant jelly-like stools are a classic sign of intussusception, a different condition where part of the intestine telescopes into itself. While abdominal distention can occur in pyloric stenosis, the presence of currant jelly-like stools points to a different diagnosis.

Choice C reason:

A rounded abdomen and hypoactive bowel sounds can be seen in various gastrointestinal conditions but are not specific to hypertrophic pyloric stenosis. While a rounded abdomen may be present due to gastric distention, hypoactive bowel sounds are not a hallmark of this condition. The primary symptom of pyloric stenosis is projectile vomiting.

Choice D reason:

Ravenously hungry after vomiting is a classic manifestation of hypertrophic pyloric stenosis. Infants with this condition often vomit forcefully after feeding and then appear hungry again because the food does not pass through the pylorus into the intestines. This symptom, along with projectile vomiting, is a key indicator of pyloric stenosis.

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A NICU nurse is completing an assessment on a premature infant male born at 29 weeks gestation. It is noted that the male infant has no palpable testes in the scrotum. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration?

Correct Answer is A

Explanation

The nurse is caring for a 5-week-old infant with suspected hypertrophic pyloric stenosis. Which clinical manifestation would indicate this condition?

Correct Answer is D

Explanation

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