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 D
Explanation
Choice A rationale
Talking to the baby each day at a special time can help build a bond and promote language development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice B rationale
Having many caregivers caring for the baby can lead to inconsistency in caregiving. According to Erikson’s theory of psychosocial development, infants need consistent and reliable caregiving to develop a sense of trust. Multiple caregivers can create confusion and insecurity for the baby.
Choice C rationale
Stimulating the baby with many toys can promote cognitive and motor development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice D rationale
Responding to the baby’s needs consistently is the most important factor in promoting the infant’s development of trust. According to Erikson’s theory, infants develop trust when their caregivers are reliable and responsive to their needs. This consistent caregiving helps the baby feel secure and builds a foundation for healthy emotional development. .
Correct Answer is A
Explanation
Choice A rationale
A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.
Choice B rationale
While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.
Choice C rationale
The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.
Choice D rationale
The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A.