Maternity Nursing Q 113
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?
A. Notify the physician immediately.
B. Administer antidiarrheal medications.
C. Monitor child every 30 minutes.
D. Nothing, this is characteristic of Hirschsprung disease.
Correct Answer: A. Notify the physician immediately.
For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately.
Option B: Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease.
Option C: The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.
Option D: Hirschsprung disease typically presents with chronic constipation. Hirschsprung’s disease (congenital megacolon) is caused by the failed migration of colonic ganglion cells during gestation. Varying lengths of the distal colon are unable to relax, causing functional colonic obstruction.