A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?

Choice A rationale:

Ribbon-like stools are a classic sign of Hirschsprung's disease, indicating narrowed or obstructed bowel segments due to the absence of ganglion cells in the intestine's muscular layers.

Choice B rationale:

A distended abdomen is common in Hirschsprung's disease due to the accumulation of stool and gas in the narrowed segments of the intestine.

Choice C rationale:

Chronic constipation is a result of the dysfunctional intestinal motility caused by Hirschsprung's disease. The absence of ganglion cells leads to a lack of peristalsis and difficulty passing stools.

Choice D rationale:

Black and tarry stools are indicative of upper gastrointestinal bleeding, often caused by conditions like peptic ulcers. This finding is not directly related to Hirschsprung's disease.

Choice A rationale:

Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.

Choice B rationale:

Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.

Choice C rationale:

Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.

Choice D rationale:

Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.