A nurse is caring for an 18-month-old infant.
The Correct Answer is []
Condition: Intussusception
Actions to Take:
- Place child on NPO status - The child should not receive oral intake to prevent aspiration and to prepare for potential surgical intervention or a procedure like an air enema, which is commonly used to treat intussusception.
- Prepare child for air enema - An air enema is the preferred non-surgical treatment for intussusception. It may help reduce the telescoping of the bowel and restore normal bowel function.
Parameters to Monitor:
- Stool patterns - Red, jelly-like stools are a key characteristic of intussusception, which is caused by the telescoping of the intestines. Monitoring stool patterns helps assess the progression and resolution of the condition.
- Abdominal pain - The child is already experiencing severe abdominal pain, often associated with intussusception. Ongoing monitoring of pain will help gauge the effectiveness of treatment and any changes in the condition.
Rationale
Intussusception is a condition where one part of the intestine slides into another, leading to obstruction. It is a common cause of abdominal pain and is characterized by red, jelly-like stools due to the presence of blood and mucus. The child's symptoms, including abdominal pain, crying, and the palpable mass, strongly suggest this condition.
Air enema is a non-invasive treatment that can reduce the telescoped segment of the intestine, often resolving the issue without the need for surgery.
Stool patterns and abdominal pain are both critical indicators of the condition's progress, and careful monitoring will help guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Water alone is not the best option for rehydration in cases of gastroenteritis. It does not replace lost electrolytes, which are essential in such situations.
B. Broth may provide some hydration, but it can be too high in sodium and lacks the proper electrolyte balance for rehydration.
C. Oral rehydration solutions (ORS) are specifically formulated to replace fluids and electrolytes lost during gastroenteritis. They help prevent dehydration and maintain electrolyte balance.
D. Diluted apple juice is not appropriate for rehydration. It lacks the necessary electrolytes and can even worsen diarrhea due to its sugar content.
Correct Answer is C
Explanation
A. Half-strength infant formula is not a clear liquid and may be too complex for an infant recovering from surgery.
B. Sterile water does not provide essential electrolytes for hydration after surgery, which the infant needs to prevent dehydration.
C. Oral electrolyte solution is the best option for rehydrating a post-surgery infant as it provides the necessary fluids and electrolytes to support recovery.
D. Half-strength orange juice is not ideal after surgery as its acidity may irritate the stomach and intestines.
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