A nurse is caring for a 3-day-old newborn and suspects Hirschsprung disease. What finding best supports the nurse's concern?
The infant has passed several tar-like stools.
The infant has not gained weight and has stooled once.
The infant has not stooled.
The infant has passed hard, pellet-like stools.
The Correct Answer is C
Rationale:
A. Passing tar-like stools is normal for newborns within the first few days of life and does not indicate Hirschsprung disease.
B. Limited stooling and poor weight gain may suggest feeding issues but are not as indicative of Hirschsprung disease as the absence of stool.
C. The absence of stool (failure to pass meconium within 24-48 hours) is a classic sign of Hirschsprung disease, a condition where the absence of ganglion cells in the intestines leads to a blockage.
D. Passing hard, pellet-like stools may indicate constipation but is not specific to Hirschsprung disease, especially in a newborn.
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Correct Answer is D
Explanation
Rationale:
A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.
B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.
C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.
D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.
Correct Answer is D
Explanation
Rationale:
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.