A nurse is caring for a toddler who has intussusception.

Which of the following manifestations should the nurse expect?

Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.

Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.