During an assessment of the newborn, the nurse expects to see ...

[ETearle]

During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked?
 
  a. Jerking of the legs
  b. Flexion of the knees
  c. Quick contraction of the sphincter
  d. Relaxation of the external sphincter

Question 2

While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next?
 
  a. Continue with the examination, and document the finding in the chart.
  b. Instruct the patient to return for a repeat assessment in 1 month.
  c. Tell the patient that a mass was felt, but it is nothing to worry about.
  d. Report the finding, and refer the patient to a specialist for further examination.

[Carliemb17]

Answer to Question 1

ANS: C
To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and noticing a quick contraction of the sphincter. The other responses are not correct.

Answer to Question 2

ANS: D
A firm or hard mass with an irregular shape or rolled edges may signify carcinoma. Any mass that is discovered should be promptly reported for further examination. The other responses are not correct.

[ETearle]

Excellent

[marict]

TYSM