A 3-month-old is being evaluated for possible Hirschsprung disease. His parents call the nurse and show his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and has a very distended abdomen. Which should be the nurse's next action?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is Option C: Immediately obtain all vital signs with a quick head-to-toe assessment. This response is the most appropriate because the infant is presenting with concerning symptoms such as mucus and bloody diarrhea, irritability, and a distended abdomen. These signs could indicate a serious condition like Hirschsprung disease, which requires prompt evaluation and intervention. Option A is incorrect because dismissing these symptoms as common or expected could delay necessary medical attention. Option B is also incorrect as there is no indication of a cardiac arrest situation based on the symptoms described. Option D is not the most immediate or comprehensive action needed in this urgent situation. From an educational perspective, this question assesses the nurse's ability to prioritize and respond to urgent pediatric gastrointestinal symptoms. Understanding the significance of these symptoms and the need for rapid assessment and intervention is crucial in providing safe and effective care to pediatric patients. This scenario highlights the importance of recognizing red flag symptoms in infants and taking prompt action to ensure their well-being.

Correct Answer: B

Rationale: The correct answer is B) Administer intravenous fluids and antibiotics. In the pre-operative period for a newborn with tracheoesophageal fistula, administering intravenous fluids and antibiotics is essential to prevent infection and maintain hydration. Surgery on the gastrointestinal system poses a risk of contamination, making antibiotic prophylaxis crucial. Intravenous fluids help maintain the infant's hydration status and electrolyte balance. Option A is incorrect because vital signs monitoring is important but insufficient for pre-operative care. Allowing parents to hold their infant can provide comfort and emotional support. Option C is incorrect as 100% oxygen via a non-rebreather mask is not typically indicated in this situation and may not address the immediate needs of the newborn. Option D is incorrect because feeding should be stopped well before surgery to prevent aspiration during induction of anesthesia. The infant should be kept NPO (nothing by mouth) for a sufficient time before surgery to reduce the risk of aspiration during the procedure. For nursing students preparing for the NCLEX, understanding the pre-operative care requirements for pediatric surgical patients is crucial. This scenario highlights the importance of infection prevention, hydration management, and NPO status before surgery in infants with tracheoesophageal fistula. It reinforces the need for evidence-based practice in pediatric nursing care.

Correct Answer: D

Rationale: The correct answer is D: Although your child will require surgery, there are different ways to manage the disease depending on how much of the bowel is involved. Rationale: - Correct Answer Explanation: Hirschsprung disease is a congenital condition where nerve cells are missing in the colon, leading to bowel obstruction. Surgery is the primary treatment, and the extent of surgery depends on how much of the bowel is affected. Different surgical approaches may be used to manage the condition effectively. - Incorrect Answers Explanation: A) Option A is incorrect because Hirschsprung disease requires surgical intervention and stool softeners alone will not resolve the condition. B) Option B is incorrect as colostomy is not the first-line treatment for Hirschsprung disease. Surgery aims to remove the affected segment of the bowel and reestablish normal bowel function. C) Option C is incorrect as daily bowel irrigations are not the mainstay of treatment for Hirschsprung disease. Surgery is the definitive treatment. Educational Context: Understanding the management of Hirschsprung disease is crucial for pediatric nurses as they care for children with this condition. By knowing the appropriate interventions, nurses can educate parents effectively and provide optimal care to the child. Highlighting the importance of surgical management and individualized treatment plans based on the extent of bowel involvement helps nurses deliver comprehensive care and support to families facing this diagnosis.

Correct Answer: C

Rationale: The correct answer is option C: "Pyloric stenosis can run in families and is more common among males." This response is accurate because pyloric stenosis has been found to have a genetic component, with a higher incidence among males. Educating the parent about the familial nature of the condition is essential for them to understand the potential risk factors for their future children. Option A is incorrect because it does not directly address the parent's question about the likelihood of future children having pyloric stenosis. Option B is incorrect as it inaccurately states that it is very rare for more than one child in a family to have pyloric stenosis, which is not supported by evidence. Option D is incorrect because pyloric stenosis can affect both males and females, although it is more common in males. In an educational context, understanding the genetic predisposition for certain conditions can help families make informed decisions about their future and possibly take preventive measures. It also highlights the importance of obtaining accurate information from healthcare providers to address any concerns or misconceptions.

Correct Answer: B

Rationale: In this scenario, option B is the correct answer because if the hernia appears more swollen or tender, seeking immediate medical care is crucial to prevent complications like incarceration or strangulation. This is important information for parents to know to ensure timely intervention and prevent potential harm to the infant. Option A is incorrect because surgery for an umbilical hernia is usually not recommended before the age of 4-5 years unless complications arise. Option C is incorrect as placing a pressure dressing can be harmful and is not a recommended treatment for an umbilical hernia. Option D is incorrect because while there is a possibility of hernia recurrence after surgical repair, it is not described as a strong likelihood. Educationally, this question serves to reinforce the importance of parental education and early recognition of signs of complications related to umbilical hernias in infants. It highlights the significance of prompt medical attention in such situations to ensure the well-being of the child. By understanding these key points, nurses can effectively educate parents on appropriate care and response to umbilical hernias in infants.