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A nurse is caring for an infant on an inpatient pediatric unit.

Select words from the choices below to fill in each blank in the following sentence.

Exhibits

When planning care for the infant, the nurse should

and .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

When planning care for the infant, the nurse should prepare the infant for a rectal biopsy and frequently measure abdominal circumference.

 

Rationale for correct answers:

 

Prepare the infant for a rectal biopsy: Confirms diagnosis of Hirschsprung disease, which is suspected based on symptoms and enema findings.

Frequently measure abdominal circumference: Monitors abdominal distension, a key sign in bowel obstruction or worsening condition.

Rationale for incorrect answers:

Explain the purpose of the pyloromyotomy: This procedure is for pyloric stenosis, not Hirschsprung disease.

Transport the client for a radiologist guided gas enema: Contrast enema already performed.

Administer oral laxatives: Contraindicated in suspected bowel obstruction like Hirschsprung disease.


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Related Questions

Correct Answer is C

Explanation

A. Polyuria:

Not associated with intussusception. It's more often seen in conditions like diabetes.

B. Scaphoid abdomen:

A scaphoid (sunken) abdomen is more associated with diaphragmatic hernia, not intussusception.

C. Gelatinous red stool:

"Currant jelly" stools (blood and mucus) are a classic sign of intussusception.

D. Generalized edema:

Edema is not a typical manifestation of intussusception.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Potential Intervention

Expected

Unexpected

Rationale

Have child tilt head back

✅

Tilting the head back increases the risk of blood being swallowed, which can cause nausea or aspiration.

Insert cotton into nostril

✅

Cotton can be ineffective and may dislodge, worsening bleeding. Use gauze or a nasal tampon if needed.

Apply ice to bridge of nose

✅

Cold vasoconstricts blood vessels, helping reduce nasal bleeding.

Apply pressure to tip of nose for at least 10 min

✅

First-line measure for anterior epistaxis. Correct site is the soft part (lower third) of the nose.

Prepare to administer factor VIII

✅

The child has a Factor VIII deficiency (35%), which is diagnostic of Hemophilia A. Factor VIII replacement is the treatment.

Prepare to administer topical antifibrinolytic agent

✅

These agents help stabilize clots and are used for mucosal bleeds in hemophilia.

Prepare to administer packed red blood cells

✅

Not indicated unless there is severe blood loss with signs of anemia or hemodynamic instability, which is not present here.

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