The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored.
This child should receive follow- up assessment for what condition?
Intussusception.
Biliary atresia.
Hirschsprung's disease.
Huntington's disease.
The Correct Answer is B
Biliary atresia is a condition that can cause jaundice in newborns and infants, and it can also lead to tea-colored urine due to the presence of bilirubin in the urine. Infants with biliary atresia require further assessment and treatment, including possible surgery, to prevent liver damage and other complications.
A. Intussusception is a condition in which a part of the intestine folds into itself, causing an obstruction, but it does not typically present with jaundice or tea-colored urine.
C. Hirschsprung's disease is a congenital condition that affects the large intestine and can cause bowel obstruction, but it also does not typically present with jaundice or tea-colored urine.
D. Huntington's disease is a genetic neurological disorder that typically does not present in infants and does not cause jaundice or tea-colored urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
Correct Answer is D
Explanation
To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuffed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and offering bubbles (C ) may distract the child but do not directly involve them in the procedure.
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