A child diagnosed with Hirschsprung's disease is scheduled for surgery. Which of the following actions should the nurse include in the preoperative care for this child? (Select All that Apply.)
Measure abdominal girth
Teach the child deep breathing exercises
Assess the child's bowel function with characteristics of stool
Administer isotonic enema to evacuate bowel
Administer an antibiotic as per order
Restrict the child's fluid intake
Assess vomiting
Correct Answer : A,C,E,G
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.
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Related Questions
Correct Answer is B
Explanation
A. Encouraging the child to be more physically active to increase calorie expenditure. – Incorrect. A child with failure to thrive (FTT) requires adequate caloric intake, and excessive activity could further contribute to weight loss.
B. Provide education on growth and development and parenting skills. – Correct. Many cases of FTT result from inadequate nutrition due to parental knowledge deficits. Educating parents on feeding techniques and child development helps promote growth.
C. Restricting fluids to prevent excessive weight gain. – Incorrect. FTT is characterized by inadequate weight gain, not excessive weight. Hydration is essential for overall health.
D. Encouraging the child to eat less to promote weight loss. – Incorrect. The goal of FTT management is to increase caloric intake to support proper growth and development.
Correct Answer is D
Explanation
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.
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