The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for ...
Test 3 Saunders & Davis NCLEX questions with
correct answers
The clinic nurse reviews the record of an infant and notes that the health
care provider has documented a diagnosis of suspected Hirschsprung's
disease. The nurse reviews the assessment findings documented in the
record, knowing that which symptom most likely led the mother to seek
health care for the infant?
1.
Diarrhea
2.
Projectile vomiting
3.
Regurgitation of feedings
4.
Foul-smelling ribbon-like stools Correct Answer-4
Hirschsprung's disease is a congenital anomaly also known as congenital
aganglionosis or aganglionic megacolon. It occurs as the result of an
absence of ganglion cells in the rectum and other areas of the affected
intestine. Chronic constipation beginning in the first month of life and
resulting in pellet-like or ribbon-like stools that are foul-smelling is a
clinical manifestation of this disorder. Delayed passage or absence of
meconium stool in the neonatal period is also a sign. Bowel obstruction
,especially in the neonatal period, abdominal pain and distention, and
failure to thrive are also clinical manifestations. Options 1, 2, and 3 are
not associated specifically with this disorder.
An infant has just returned to the nursing unit after surgical repair of a
cleft lip on the right side. The nurse should place the infant in which best
position at this time?
1.
Prone position
2.
On the stomach
3.
Left lateral position
4.
Right lateral position Correct Answer-3
A cleft lip is a congenital anomaly that occurs as a result of failure of
soft tissue or bony structure to fuse during embryonic development.
After cleft lip repair, the nurse avoids positioning an infant on the side of
the repair or in the prone position because these positions can cause
rubbing of the surgical site on the mattress. The nurse positions the
infant on the side lateral to the repair or on the back upright and
positions the infant to prevent airway obstruction by secretions, blood,
,or the tongue. From the options provided, placing the infant on the left
side immediately after surgery is best to prevent the risk of aspiration if
the infant vomits.
The nurse reviews the record of a newborn infant and notes that a
diagnosis of esophageal atresia with tracheoesophageal fistula is
suspected. The nurse expects to note which most likely sign of this
condition documented in the record?
1.
Incessant crying
2.
Coughing at nighttime
3.
Choking with feedings
4.
Severe projectile vomiting Correct Answer-3
In esophageal atresia and tracheoesophageal fistula, the esophagus
terminates before it reaches the stomach, ending in a blind pouch, and a
fistula is present that forms an unnatural connection with the trachea.
Any child who exhibits the "3 C's"-coughing and choking with feedings
and unexplained cyanosis-should be suspected to have
, tracheoesophageal fistula. Options 1, 2, and 4 are not specifically
associated with tracheoesophageal fistula.
The nurse provides feeding instructions to a parent of an infant
diagnosed with gastroesophageal reflux disease. Which instruction
should the nurse give to the parent to assist in reducing the episodes of
emesis?
1.
Provide less frequent, larger feedings.
2.
Burp the infant less frequently during feedings.
3.
Thin the feedings by adding water to the formula.
4.
Thicken the feedings by adding rice cereal to the formula. Correct
Answer-4
Gastroesophageal reflux is backflow of gastric contents into the
esophagus as a result of relaxation or incompetence of the lower
esophageal or cardiac sphincter. Small, more frequent feedings with
frequent burping often are prescribed in the treatment of
gastroesophageal reflux. Feedings thickened with rice cereal may reduce
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