A nurse is collecting data from an infant who has Hirschsprung's disease. Which of the following manifestations should the nurse expect?

Abdominal distention.

Steatorrhea.

Blood-tinged emesis.

Dysphagia.

Answer and Explanation

The Correct Answer is A

Abdominal distention. Choice A reason:

Abdominal distention is a common manifestation of Hirschsprung's disease in infants. This condition is characterized by the absence of ganglion cells in the distal segment of the colon, leading to a functional obstruction. The absence of ganglion cells causes the affected part of the colon to become narrow and unable to relax, resulting in a buildup of stool and gas, leading to abdominal distention.

Choice B reason:

Steatorrhea, which is the presence of fatty, bulky, and foul-smelling stools, is not typically associated with Hirschsprung's disease. This manifestation is more commonly seen in conditions affecting the pancreas, liver, or small intestine, where the digestion and absorption of fats are impaired.

Choice C reason:

Blood-tinged emesis (vomiting) is not a typical manifestation of Hirschsprung's disease. This symptom is more commonly associated with gastrointestinal bleeding, which can be caused by various factors such as ulcers, esophageal varices, or gastritis.

Choice D reason:

Dysphagia, which refers to difficulty swallowing, is also not a characteristic manifestation of Hirschsprung's disease. Dysphagia is more commonly seen in conditions affecting the esophagus or throat, such as esophageal strictures or neurological disorders affecting swallowing reflexes.

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Correct Answer is B

Explanation

Choice A reason: Following the rupture of membranes, delivery is imminent and administration of glucocorticoids may not take effect to benefit the baby.

Choice B reason:

Monitoring the client's temperature (Choice B) is important as the client is at risk of chorioamnionitis which may increase the risk of severe early neonatal sepsis. Changes in temperature as they may warrant anibiotic therapy and immediate delivery.

Choice C reason:

Giving calcium gluconate (Choice C) is not indicated in this situation. Calcium gluconate is typically administered in cases of magnesium sulfate toxicity or to treat hypocalcemia, neither of which is mentioned in the scenario. Therefore, it is not the appropriate action for the nurse to take at this time.

Choice D reason:

Preparing the client for an amniocentesis (Choice D) is not the correct action in this situation. An amniocentesis is a procedure in which a small amount of amniotic fluid is withdrawn for various diagnostic reasons, such as genetic testing or assessing fetal lung maturity. However, in this scenario, the priority is to administer glucocorticoids to promote fetal lung maturity, and an amniocentesis does not address this immediate concern.

A. "I will wash off the ointment with each diaper change.” B. "I should shake talcum powder onto the reddened areas.” C. "I should dry the diaper area with a hair dryer on the lowest setting.” D. "I will use moist disposable wipes that are detergent free.”

Correct Answer is D

Explanation

Choice A reason:

Washing off the zinc oxide ointment with each diaper change would not be beneficial for the infant's diaper dermatitis. Zinc oxide ointment forms a protective barrier on the skin, and frequent washing could remove this barrier, reducing its effectiveness in promoting healing and protecting the irritated skin.

Choice B reason:

Shaking talcum powder onto the reddened areas is not a suitable approach. Talcum powder can further irritate the skin and worsen the diaper dermatitis. It is best to avoid using talcum powder on an infant's delicate skin.

Choice C reason:

Using a hair dryer, even on the lowest setting, to dry the diaper area is not recommended. The hot air from the hair dryer can be too harsh for the infant's sensitive skin and might exacerbate the irritation. It is safer to let the diaper area air dry naturally or pat it gently with a soft cloth.

Choice D reason:

This is the correct choice. Using moist disposable wipes that are detergent-free is a suitable option for cleaning the infant's diaper area. Detergent-free wipes are gentle on the skin and less likely to cause further irritation. Additionally, keeping the area clean and dry is essential for managing diaper dermatitis, and these wipes can help achieve that without causing harm.

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A nurse is collecting data from an infant who has Hirschsprung's disease. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is at 36 weeks of gestation and experienced preterm prelabor rupture of membranes. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a parent of an infant who has diaper dermatitis and a new prescription for zinc oxide ointment. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

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