A nurse is caring for a preschooler who has strabismus. Which of the following should the nurse identify as a possible complication of this condition?

A. Bradycardia, rapid weight gain, and irritability. – Incorrect. Tachycardia (not bradycardia) is more concerning in worsening heart failure.

B. Cough, edema, and increased work of breathing. – Incorrect. These symptoms can occur but are less specific to worsening heart failure in infants.

C. Abdominal pain, poor appetite, and cough. – Incorrect. While appetite changes may occur, abdominal pain is not a classic sign of heart failure in infants.

D. Tachypnea and diaphoresis with feeding, poor weight gain, and irritability. – Correct. Infants with worsening heart failure experience increased respiratory effort, sweating with feeds (due to exertion), failure to thrive, and fussiness due to poor oxygenation.

A. Measure abdominal girth – Correct. Measuring abdominal girth helps monitor for signs of obstruction, which is common in Hirschsprung’s disease due to the absence of ganglion cells in the colon.

B. Teach the child deep breathing exercises – Incorrect. Deep breathing exercises are not typically taught to infants or young children undergoing surgery for Hirschsprung’s disease.

C. Assess the child's bowel function with characteristics of stool – Correct. Assessing stool patterns is important since Hirschsprung’s disease is characterized by an absence of peristalsis in the affected bowel.

D. Administer isotonic enema to evacuate bowel – Incorrect. Enemas are contraindicated in Hirschsprung’s disease as they can lead to bowel perforation.

E. Administer an antibiotic as per order – Correct. Preoperative antibiotics are given to prevent infection.

F. Restrict the child's fluid intake – Incorrect. Fluid restriction is not necessary and may worsen dehydration, especially if the child has vomiting or diarrhea.

G. Assess vomiting – Correct. Vomiting can indicate worsening obstruction or enterocolitis, a serious complication of Hirschsprung’s disease.