A nurse is caring for an 18-month-old infant.

Exhibits

The nurse has completed the child's admission assessment.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential condition- Intussusception

Intussusception is a condition where one part of the intestine folds into another part, causing an obstruction. It is common in infants and toddlers and typically presents with the following signs- Severe abdominal pain, which causes the child to pull their knees to their chest (classic sign of colicky abdominal pain), red, jelly-like stools (which indicate the presence of blood and mucus in the stool) and palpable mass in the right upper quadrant (which could be the telescoping portion of the bowel).

Actions to Take

Place child on NPO status:

The child should be placed on nothing by mouth (NPO) status to prepare for potential procedures, such as an enema or surgery. This prevents aspiration during any intervention and ensures the bowel is not further irritated by food or liquid intake.

Prepare child for an air enema:

Air enema is a non-invasive treatment for intussusception. It is often used to reduce the telescoping bowel by using air under fluoroscopic guidance. This treatment can resolve the condition in many cases without the need for surgery. The nurse must ensure the child is properly prepared for this procedure (e.g., ensuring the child is NPO, monitoring vitals, and explaining the procedure to the family).

Parameters to Monitor

Stool patterns:

Monitoring the stool patterns is essential to assess the progress and severity of intussusception. The presence of red, jelly-like stools (blood and mucus) is characteristic of intussusception, and any changes in stool appearance can help evaluate the effectiveness of treatment. The nurse should monitor if the stool pattern changes after the air enema or surgical intervention.

Abdominal pain:

Abdominal pain is a hallmark symptom of intussusception, and the nurse should continually assess the child's pain level. The child may experience intermittent, severe cramp-like pain due to the bowel obstruction. Monitoring and managing the pain effectively is crucial for patient comfort and well-being.

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Free Nursing Study Resources

Correct Answer is ["C","D","E","F"]

Explanation

A. Encouraging vigorous physical activity is not appropriate for an infant with RSV, as it can worsen respiratory distress.
B. Antibiotics are not effective against RSV because it is a viral infection. Antibiotics should only be used for secondary bacterial infections.
C. Isolation is crucial to prevent the spread of RSV to other infants, especially in healthcare settings.
D. Bronchodilators may be used to help open the airways and ease breathing in some cases of RSV.
E. Small, frequent feedings are important to prevent dehydration, as infants with RSV may struggle with feeding due to difficulty breathing.
F. Oxygen therapy is often required to maintain adequate oxygen levels in infants with RSV, particularly if they are experiencing respiratory distress.

A. Administer codeine postoperatively for pain management. B. Offer the child a straw to drink fluids more easily. C. Encourage the child to blow their nose gently to clear any mucus or secretions. D. Monitor for evidence of bleeding, such as frequent swallowing or bright red emesis.

Correct Answer is D

Explanation

A. Although pain management is an important aspect of post-operative care, opioid use such as codeine is generally avoided in children due to the risk of respiratory depression and other side effects. Non- opioid pain relievers are preferred for post-tonsillectomy care.
B. While it is important for the child to stay hydrated after a tonsillectomy, using a straw can increase the risk of trauma to the surgical site, leading to bleeding. The nurse should encourage sipping liquids carefully without using a straw.
C. Blowing the nose after a tonsillectomy can cause pressure that may disrupt the healing tissue, increasing the risk of bleeding. This action should be avoided in the post-operative period.
D. Bleeding is a significant concern after a tonsillectomy, especially in the first 24 hours. Frequent swallowing may indicate that the child is swallowing blood, and bright red emesis (vomiting) may also signal active bleeding. Monitoring for signs of bleeding is the nursing priority, as it can be life- threatening if not addressed promptly.

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Actions to Take

Parameters to Monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant with respiratory syncytial virus (RSV). Which of the following are appropriate nursing interventions when prioritizing care for an infant with RSV? (Select All that Apply.)

Correct Answer is ["C","D","E","F"]

Explanation

A nurse is caring for a child post-operative tonsillectomy, what is the nursing priority when providing post-operative care?

Correct Answer is D

Explanation

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