A nurse is caring for a 3-month-old male infant in an inpatient pediatric unit.
Which of the following actions should the nurse prioritize for the infant with suspected Hirschsprung’s disease?
Administer a glycerin suppository to stimulate bowel movement.
Prepare the infant for a rectal biopsy as prescribed.
Initiate oral rehydration therapy to correct fluid imbalance.
Administer antibiotics to treat potential infection.
The Correct Answer is B
Choice A rationale: Glycerin suppositories may stimulate rectal evacuation by osmotic action, but they are ineffective in Hirschsprung’s disease due to aganglionic rectal segments lacking neuromuscular coordination. The pathophysiology involves absence of enteric ganglion cells, leading to functional obstruction. Administering stimulants in this context may worsen discomfort or delay diagnostic clarity. Therapeutic focus should shift toward confirming diagnosis and planning definitive surgical management, not symptom suppression through inappropriate pharmacologic stimulation.
Choice B rationale: Rectal biopsy is the gold standard for diagnosing Hirschsprung’s disease, which stems from failure of neural crest cell migration, leading to aganglionosis in the distal colon. Biopsy evaluates for absence of ganglion cells in the submucosal and myenteric plexuses. Confirmatory diagnosis enables planning for pull-through surgical procedures. Biopsy prioritization is critical when symptoms include delayed meconium passage, abdominal distention, explosive diarrhea, and a transition zone on imaging—all hallmark findings of Hirschsprung’s disease.
Choice C rationale: Oral rehydration may seem appropriate in mild dehydration, but in Hirschsprung’s disease, fluid losses stem from poor absorption and structural bowel defects. Explosive watery stools reflect overflow diarrhea, not hyperosmolar loss. Moreover, oral intake may exacerbate abdominal distention. Parenteral fluid resuscitation may be more appropriate pending diagnostic confirmation and surgical consultation. Fluid correction must be guided by systemic signs and done cautiously to avoid worsening bowel symptoms.
Choice D rationale: Antibiotics are not routinely indicated unless enterocolitis or sepsis is confirmed. Fever alone is nonspecific and may reflect systemic inflammation due to bowel obstruction. Hirschsprung’s-associated enterocolitis presents with toxic signs like vomiting, fever, bloody diarrhea, and lethargy, not just distention and watery stool. Initiating antibiotics prematurely may mask infection or delay focused diagnosis. A careful diagnostic approach, starting with biopsy, takes precedence to confirm structural bowel abnormality. MWISHO
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Choice A rationale
A rectal biopsy is a definitive diagnostic tool for conditions like Hirschsprung's disease, which presents similarly to the clinical scenario implied. However, administering oral laxatives may not be appropriate in this context, as it could exacerbate symptoms or be contraindicated depending on the specific underlying pathology of the infant's digestive system. The choice of intervention must align with the specific disease process.
Choice B rationale
A pyloromyotomy is the surgical procedure of choice for pyloric stenosis, a condition in which the pyloric sphincter is hypertrophied, obstructing gastric emptying. A hallmark symptom is projectile vomiting, which leads to malnutrition and dehydration. Consequently, measuring abdominal circumference frequently is a crucial nursing intervention to monitor for abdominal distention or changes related to the infant's condition and to assess for potential complications post-operatively.
Choice C rationale
A radiologist-guided gas enema, also known as a therapeutic air enema, is a common non-surgical treatment for intussusception, which is the telescoping of a bowel segment into another. This procedure utilizes air pressure to reduce the intussusception. Transporting the client is a generic nursing action and not a specific, focused intervention directly related to the procedure's scientific principles or the infant's immediate care needs.
Choice D rationale
A rectal biopsy is used to confirm the diagnosis of Hirschsprung's disease by detecting the absence of ganglion cells in the distal colon. However, explaining the purpose of the procedure to an infant is developmentally inappropriate, as infants lack the cognitive ability to comprehend such information. The explanation should be directed to the parents or legal guardians, not the infant themselves.
Correct Answer is A
Explanation
Choice A rationale
Infective endocarditis is a bacterial or fungal infection of the inner lining of the heart, most commonly affecting the heart valves. The presence of vegetation on the heart valves can alter blood flow dynamics, leading to the development of a new or changing heart murmur. This is a classic and significant clinical finding associated with the disease and is a key diagnostic criterion.
Choice B rationale
Weight gain is not a typical finding in a child with infective endocarditis. The infection is a catabolic state that often leads to a poor appetite, lethargy, and a general state of illness, which usually results in weight loss or a failure to thrive. Weight gain, particularly in the context of heart failure, is more indicative of fluid retention, which can be a complication but is not an initial finding.
Choice C rationale
Bradycardia, a slow heart rate, is an unexpected finding in infective endocarditis. The systemic inflammatory response to the infection typically leads to an increase in metabolic demand and a compensatory response, causing tachycardia (a fast heart rate) to meet the body's needs. Bradycardia is more often associated with conditions such as heart block or certain medications.
Choice D rationale
A decreased body temperature is not expected. The systemic infection and inflammatory response characteristic of infective endocarditis almost always result in a fever, which is one of the most common and persistent signs of the disease. A normal body temperature in children is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F).
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