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. Bottle-feed with diluted fruit juice:
Incorrect: Diluted fruit juice is not recommended for infants with diarrhea. Fruit juices, even when diluted, may contain sugars that can exacerbate diarrhea. It's important to focus on water or rehydration solutions.
B. Discontinue breast-feeding until the diarrhea resolves:
Incorrect: Breast milk is an essential source of nutrition for infants, and discontinuing breastfeeding is not recommended, even during episodes of mild diarrhea. Breast milk helps maintain hydration and provides essential nutrients.
C. Provide an increased intake of water.
Correct Answer: Maintaining hydration is crucial during episodes of diarrhea. Offering the infant increased water intake helps prevent dehydration. Rehydration solutions specifically designed for infants can also be recommended.
D. Avoid all solid foods:
Incorrect: While avoiding certain solid foods may be recommended in some cases, it's not necessary to completely avoid all solid foods for a 12-month-old with mild diarrhea. The emphasis should be on maintaining hydration and offering easily digestible foods.
Correct Answer is ["A","C","D"]
Explanation
A. Lateral deviation and rotation of each vertebra:
Correct Answer: Correct.
Explanation: Scoliosis involves a lateral (side-to-side) curvature of the spine and often includes some degree of vertebral rotation. Assessing for these deviations is crucial in diagnosing scoliosis.
B. Equal rib prominences:
Correct Answer: Incorrect.
Explanation: In scoliosis, the ribs may appear more prominent on one side due to the lateral curvature of the spine. Therefore, equal rib prominences would not typically be observed in scoliosis.
C. Unequal rib heights:
Correct Answer: Correct.
Explanation: Unequal heights of the ribs are commonly seen in scoliosis due to the asymmetrical nature of the spine's curvature.
D. Chest asymmetry:
Correct Answer: Correct.
Explanation: Asymmetry in the chest area, including differences in the shape or appearance of the chest, can be indicative of scoliosis, especially when associated with the spinal curvature.
E. Equal shoulder heights:
Correct Answer: Incorrect.
Explanation: In scoliosis, one shoulder might appear higher than the other due to the lateral curvature of the spine. Therefore, equal shoulder heights would not typically be observed in scoliosis.
F. Equal waist angles:
Correct Answer: Incorrect.
Explanation: Scoliosis often causes an asymmetrical appearance of the waistline due to the lateral curvature of the spine, resulting in unequal waist angles rather than equal ones.
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