A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration?

The correct answer is Choice C: Measure abdominal girth.

Choice A rationale:

Taking vital signs, including blood pressure, is important in assessing the overall health status of a child, but it might not provide specific information about a probable intussusception. Blood pressure is not typically affected in a way that directly relates to intussusception.

Choice B rationale:

Auscultating for bowel sounds is an important assessment technique in various gastrointestinal conditions, but it may not be the most appropriate immediate action when dealing with a probable intussusception. While bowel sounds might be diminished or absent in intussusception, the priority should be on assessing other signs and symptoms.

Choice C rationale:

Measuring abdominal girth is an essential nursing action when a child with a probable intussusception has a normal, brown stool. Intussusception is the telescoping of one segment of the intestine into another, often leading to bowel obstruction. Abdominal distension or girth measurement can provide valuable information about the progression of the condition and potential obstruction.

Choice D rationale:

Notifying the practitioner is an important step, but it might not be the most immediate action required. Assessing and monitoring the child's condition should be the initial response to gather more information before notifying the practitioner.

The correct answer is choice B. Epinephrine.

Choice A rationale:

Diphenhydramine. Diphenhydramine is an antihistamine commonly used to relieve allergic symptoms such as itching, rash, and runny nose. While it can be part of the treatment for anaphylactic reactions, it is not the medication of choice for immediate administration in the case of a severe anaphylactic reaction like the one described in the scenario.

Choice B rationale:

Epinephrine. Correct Answer. In cases of severe anaphylactic reactions, epinephrine (adrenaline) is the medication of choice for immediate administration. Epinephrine acts rapidly to reverse life-threatening symptoms, such as airway constriction, low blood pressure, and hives. It works by dilating airways, increasing heart rate, and improving blood pressure.

Choice C rationale:

Dopamine. Dopamine is a medication used to increase blood pressure and cardiac output in certain critical situations. However, it is not the first-line treatment for anaphylactic reactions. Epinephrine's effects on airway and cardiovascular function make it the preferred choice in this context.

Choice D rationale:

Calcium chloride. Calcium chloride is not the appropriate medication for treating anaphylactic reactions. Its main medical uses include treating hypocalcemia (low blood calcium levels) and certain cardiac arrhythmias. It does not address the primary symptoms and physiological changes associated with anaphylaxis.