A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?
Hirschsprung’s disease.
Encopresis.
Pyloric stenosis.
Enterocolitis.
The Correct Answer is A
Choice A rationale
Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.
Choice B rationale
Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Choice C rationale
Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.
Choice D rationale
Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.
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Correct Answer is C
Explanation
Choice A rationale
Auscultating for a cardiac murmur can be helpful but is not the most specific assessment for coarctation of the aorta. Murmurs can be present in various cardiac conditions.
Choice B rationale
Recording blood pressure in the upper extremities alone is not sufficient. Coarctation of the aorta often presents with a discrepancy between upper and lower extremity blood pressures.
Choice C rationale
Assessing for the presence of femoral pulses is crucial. In coarctation of the aorta, there is decreased blood flow to the lower extremities, leading to weak or absent femoral pulses.
Choice D rationale
Observing for excessive crying is non-specific and can be associated with many conditions, not just coarctation of the aorta.
Correct Answer is C
Explanation
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.