The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the parent to seek health care for the infant?
Diarrhea
Regurgitation of feedings
Projectile vomiting
Foul-smelling ribbon-like stools
The Correct Answer is D
A. Diarrhea
Explanation: Diarrhea is not a typical sign of Hirschsprung's disease. Instead, the condition is associated with constipation due to the obstructed passage of stool.
B. Regurgitation of feedings
Explanation: Regurgitation of feedings is not a characteristic sign of Hirschsprung's disease. It may be seen in other gastrointestinal conditions, but not specifically in this disorder.
C. Projectile vomiting
Explanation: Projectile vomiting is not a typical sign of Hirschsprung's disease. It may be associated with conditions such as pyloric stenosis, but it is not a characteristic feature of Hirschsprung's disease.
D. Foul-smelling ribbon-like stools
Explanation:
Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the rectum and a portion of the colon. The lack of ganglion cells results in functional obstruction, causing stool to accumulate in the affected area. One of the hallmark signs is the presence of foul-smelling, ribbon-like stools, often described as "fecal pellets" or "pellets" due to the obstructed passage of stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
Explanation: While it is appropriate to involve a supervisor in difficult situations, the nurse should first clarify the legal obligation to report suspected child abuse. This response may leave the impression that the nurse is avoiding the question.
B. "As a nurse, I am required by law to report suspected child abuse."
Explanation:
Nurses are mandated reporters, meaning they are legally obligated to report suspected child abuse. It is important to communicate this legal obligation to the parents when they inquire about the reason for the report. This response is honest, direct, and reinforces the nurse's ethical and legal responsibility to prioritize the well-being and safety of the child.
C. "I reported the incident to my supervisor who decided to contact the authorities."
Explanation: This response may create confusion about the reporting process. It is important to convey that reporting is a legal obligation for the nurse, and it is not solely at the discretion of the supervisor.
D. "The provider will be coming to explain the situation."
Explanation: While involving other healthcare professionals, such as a provider, may be part of the process, it is crucial to emphasize the nurse's legal responsibility to report suspected child abuse. This response does not clearly communicate the legal obligation that the nurse has in reporting such incidents.
Correct Answer is C
Explanation
A. 9 months: By 9 months, most infants would have well exceeded doubling their birth weight.
B. 12 months: Doubling of birth weight usually occurs earlier, by around 5 to 6 months, rather than 12 months.
C. 6 months
Explanation:
The general guideline is that infants tend to double their birth weight by around 5 to 6 months of age. This doubling of birth weight is a common marker of healthy growth and development during the first few months of life.
D. 3 months: By 3 months, while infants experience significant growth, they usually haven't doubled their birth weight yet.
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