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 B
Explanation
A. Shows preferences towards foods
Explanation: Showing preferences towards foods, such as liking some tastes more than others, is a normal developmental behavior in infants. It is not typically a cause for concern.
B. Babbles one-syllable sounds
Explanation:
By the age of 7 months, most infants should be engaging in babbling with repetitive consonant-vowel combinations. If an infant is only producing one-syllable sounds at this age, it might be a potential sign of delayed language development. Further evaluation by a healthcare provider, such as a pediatrician or a speech-language pathologist, may be warranted to assess the child's language and communication skills.
C. Uses a unidextrous grasp
Explanation: A unidextrous grasp, where the infant uses one hand to grasp objects, is a typical developmental milestone at this age. Infants typically begin to show a dominant hand preference later in their development.
D. Has a fear of strangers
Explanation: Fear of strangers, often referred to as "stranger anxiety," is a normal developmental stage that typically emerges around 6 to 9 months of age. It is a sign of social and cognitive development and is not generally a cause for concern.
Correct Answer is D
Explanation
A. "Limit your caloric intake to avoid becoming overweight."
Explanation: This statement emphasizes the importance of maintaining a healthy weight through balanced nutrition and avoiding excessive caloric intake. It promotes the prevention of overweight and obesity.
B. "Tanning beds are much safer than lying in the sun."
Explanation: This statement is incorrect. Tanning beds are not safer than natural sunlight and are associated with an increased risk of skin cancer. Adolescents should be advised to protect their skin from harmful UV radiation.
C. "Share piercing needles only with close friends you trust."
Explanation: This statement is unsafe and promotes risky behavior. Sharing piercing needles can lead to the transmission of bloodborne infections such as HIV and hepatitis. The nurse should emphasize the importance of using sterile needles and avoiding risky behaviors.
D. "Your need for sleep will increase during periods of growth."
Explanation:
During periods of growth, adolescents often experience increased physical and hormonal changes, and adequate sleep is crucial for overall health and well-being. Sleep plays a vital role in growth, immune function, and cognitive performance. Adolescents should be encouraged to prioritize getting sufficient sleep for their age group.
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