Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Sausage-shaped mass palpated in the upper right abdominal quadrant
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
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
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
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Paediatric Assessment Proctored Exam 2022. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?
A. "This test will confirm if your child had a recent streptococcal infection."
"This test will confirm if your child had a recent streptococcal infection." Explanation:The anti-streptolysin O (ASO) titer is a blood test used to detect the presence of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. A rise in ASO titers indicates a recent streptococcal infection. It does not confirm rheumatic fever directly but helps in identifying a recent streptococcal infection, which is a predisposing factor for rheumatic fever.
B. "This test will indicate if your child has rheumatic fever."
"This test will indicate if your child has rheumatic fever." Explanation: While a positive ASO titer may suggest a recent streptococcal infection, it does not directly indicate rheumatic fever. The diagnosis of rheumatic fever involves a combination of clinical criteria, including evidence of a recent streptococcal infection, along with specific signs and symptoms.
C. "This test will confirm if your child has immunity to streptococcal bacteria."
"This test will confirm if your child has immunity to streptococcal bacteria." Explanation: The ASO titer does not measure immunity to streptococcal bacteria. It specifically detects antibodies produced in response to a recent streptococcal infection.
D. "This test will indicate if your child has a therapeutic blood level of an aminoglycoside."
"This test will indicate if your child has a therapeutic blood level of an aminoglycoside." Explanation: The ASO titer is not used to monitor therapeutic blood levels of aminoglycosides. It is specific to detecting antibodies related to streptococcal infections and is not related to aminoglycoside therapy.
Full Explanation
A. "This test will confirm if your child had a recent streptococcal infection."
Explanation:
The anti-streptolysin O (ASO) titer is a blood test used to detect the presence of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. A rise in ASO titers indicates a recent streptococcal infection. It does not confirm rheumatic fever directly but helps in identifying a recent streptococcal infection, which is a predisposing factor for rheumatic fever.
B. "This test will indicate if your child has rheumatic fever."
Explanation: While a positive ASO titer may suggest a recent streptococcal infection, it does not directly indicate rheumatic fever. The diagnosis of rheumatic fever involves a combination of clinical criteria, including evidence of a recent streptococcal infection, along with specific signs and symptoms.
C. "This test will confirm if your child has immunity to streptococcal bacteria."
Explanation: The ASO titer does not measure immunity to streptococcal bacteria. It specifically detects antibodies produced in response to a recent streptococcal infection.
D. "This test will indicate if your child has a therapeutic blood level of an aminoglycoside."
Explanation: The ASO titer is not used to monitor therapeutic blood levels of aminoglycosides. It is specific to detecting antibodies related to streptococcal infections and is not related to aminoglycoside therapy.
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?
A. Test the urine for protein
Test the urine for protein.Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Reposition the infant frequently. Explanation:Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes
Assess blood pressure every 15 minutes. Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment
Provide a stimulating environment. Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
Full Explanation
A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.)
A. Stopping the medication when the child feels better
Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication
Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication
The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication
Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication
Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.
Full Explanation
A. Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication: Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication: Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.