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
A positive Babinski reflex is normal in infants up to 2 years old and indicates normal neurological development.
Choice B rationale
A negative Doll’s eye reflex is concerning as it may indicate a neurological problem. However, it is not as critical as a positive Moro reflex in a 9-month-old.
Choice C rationale
A negative Crawl reflex may indicate developmental delays, but it is not as critical as a positive Moro reflex in a 9-month-old.
Choice D rationale
A positive Moro reflex is abnormal in a 9-month-old and may indicate neurological issues. This reflex typically disappears by 2 months of age.
Correct Answer is D
Explanation
Choice A rationale
Encouraging the child to talk about the procedure is important for emotional support, but it is not the most critical assessment immediately after a cardiac catheterization. The priority is to monitor for potential complications.
Choice B rationale
Confirming to the child that the procedure has been completed is important for reassurance, but it is not the most critical assessment. The priority is to monitor for potential complications.
Choice C rationale
Gradually allowing the child to adapt to the lighted surroundings is not relevant to the immediate post-procedure care. The priority is to monitor for potential complications.
Choice D rationale
Checking pedal pulses frequently is the most important assessment after a cardiac catheterization via the femoral artery. It helps to ensure that there is adequate blood flow to the lower extremities and to detect any signs of arterial obstruction or complications at the catheter insertion site.