A nurse is caring for a 3-day-old newborn born at 39 weeks gestation. During assessment, the nurse notes that the newborn has not passed meconium since birth, has a distended abdomen, and is refusing feedings. The newborn's vital signs are stable. What is the priority nursing intervention?

Failure to pass meconium with abdominal distension and feeding refusal indicates possible Hirschsprung disease or obstruction, requiring immediate provider notification for diagnostic testing. Other options could worsen the condition or delay critical care.

Clinical Presentation and Pathophysiology

The newborn's clinical picture—failure to pass meconium within the first 24–48 hours of life, progressive abdominal distension, and refusal to feed—is a classic presentation of a distal intestinal obstruction. In a term newborn, the most critical condition to rule out is Hirschsprung disease (HD), a congenital disorder characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal bowel. This aganglionosis results in a lack of peristalsis in the affected segment, leading to functional obstruction. The fact that the newborn is now 3 days old without passing meconium makes delayed passage a significant red flag, as over 90% of healthy term newborns pass meconium within the first 24 hours. The stable vital signs are reassuring but do not reduce the urgency of identifying the underlying cause, as the obstruction can lead to enterocolitis, a life-threatening complication of HD, if not promptly diagnosed and managed ^[4].

Analysis of Interventions

Administering a glycerin suppository (Option 1) is contraindicated as a first-line intervention in a suspected case of HD. Stimulation of the rectum can temporarily evacuate stool from the distal aganglionic segment, providing false reassurance, but it does not address the functional obstruction and can delay definitive diagnosis. More critically, rectal stimulation or enemas can increase the risk of bowel perforation, especially in the transition zone where the dilated, normally innervated bowel meets the narrowed aganglionic segment. Increasing the frequency of feedings (Option 3) is dangerous because it introduces more substrate into an obstructed gastrointestinal tract, worsening abdominal distension and increasing the risk of vomiting and aspiration. Positioning the newborn prone (Option 4) is a comfort measure for gas but has no therapeutic effect on a mechanical or functional obstruction caused by aganglionosis .

Priority Nursing Action and Diagnostic Confirmation

The priority nursing intervention is to notify the healthcare provider immediately and prepare for diagnostic testing (Option 2). The nurse’s recognition of this symptom cluster as a potential surgical abdomen necessitates urgent communication. The definitive diagnostic test for HD is a rectal suction biopsy, which identifies the absence of ganglion cells and the presence of hypertrophic nerve trunks. The nurse’s role in preparing for this testing includes ensuring the newborn is kept NPO (nothing by mouth) to decompress the bowel, initiating gastric decompression via a nasogastric tube if ordered, and securing intravenous access for fluid resuscitation and maintenance. These interventions are critical to stabilizing the newborn and preventing the progression to Hirschsprung-associated enterocolitis (HAEC), a severe complication with significant morbidity and mortality .

Clinical Implications of Delayed Diagnosis

The urgency of this intervention is underscored by the documented consequences of a delayed diagnosis. A late diagnosis of HD, even when defined as occurring after 12 months of age, is associated with a higher burden of preoperative enterocolitis and more complex surgical courses . In the neonatal period, a delay of even hours can be clinically significant. The newborn in this scenario is already exhibiting signs of functional obstruction. Without prompt intervention, the risk of bacterial overgrowth, transmural infection, and potential perforation increases substantially. Early diagnosis and surgical planning, specifically a pull-through procedure, are directly linked to improved long-term functional outcomes, including continence and quality of life. The nurse’s timely clinical judgment and advocacy in reporting these findings are the first and most critical steps in preventing the cascade of complications associated with a delayed HD diagnosis ^[4].