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. Meningococcal polysaccharide vaccine
Explanation: Meningococcal vaccine is recommended for adolescents, particularly before starting college, as it helps protect against meningococcal disease. The conjugate form of the vaccine is usually preferred over the polysaccharide form.
B. Pneumococcal polysaccharide vaccine
Explanation: Pneumococcal vaccine is generally recommended for older adults and individuals with specific medical conditions, but it may not be part of routine immunizations for healthy adolescents.
C. Influenza vaccine
Explanation:
Influenza vaccine is recommended annually for adolescents as part of routine immunizations. It helps protect against the seasonal flu, which can cause significant illness and complications.
D. Bacille Calmette-Guerin (BCG) vaccine
Explanation: BCG vaccine is primarily used in some countries to prevent tuberculosis. It is not routinely administered in the United States as part of standard immunization schedules for adolescents.
Correct Answer is B
Explanation
A. Use a padded tongue blade:
Incorrect: Inserting anything into the child's mouth, including a padded tongue blade, is not recommended during a seizure. It can lead to oral and airway injuries. It's important to keep the airway clear, but this is achieved by positioning the child laterally.
B. Position the child laterally.
Correct Answer: This is the correct action. Placing the child on their side helps prevent aspiration of fluids and promotes a clear airway during the seizure. It also reduces the risk of injury.
C. Restrain the child's arms:
Incorrect: Restraining the child's arms can increase the risk of injury and is not recommended during a seizure. It's crucial to ensure a safe environment and prevent injury, but physically restraining the child is not the appropriate approach.
D. Attempt to stop the seizure:
Incorrect: It is not within the nurse's capacity to immediately stop a seizure. Seizures are neurological events, and they need to run their course. The focus should be on ensuring the safety of the child during the seizure.
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