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
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.
Correct Answer is A
Explanation
Choice A rationale
Increased crying episodes are a common indicator of pain in infants. Crying is a behavioral response to discomfort and can be more intense or frequent when the infant is in pain. This response is due to the activation of the infant’s nervous system, which signals distress through crying.
Choice B rationale
Decreased respiratory rate is not typically associated with pain in infants. Pain usually causes an increase in respiratory rate due to the body’s stress response, which involves the release of adrenaline and other stress hormones that stimulate the respiratory system.
Choice C rationale
Decreased heart rate is also not a common sign of pain in infants. Pain generally leads to an increased heart rate as part of the body’s fight-or-flight response, which is mediated by the sympathetic nervous system.
Choice D rationale
Increased formula consumption is not an indicator of pain. In fact, pain might reduce an infant’s appetite and lead to decreased feeding. Pain can cause discomfort during feeding, leading to fussiness and refusal to eat.