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

Explanation

A. While strabismus may be treated with interventions such as patching, it is not always immediately concerning in newborns. The nurse should first provide accurate information about normal development.
B. Taking the baby to the nursery may not be necessary unless the child’s condition worsens or there is a
clear concern. A thorough assessment and explanation by the nurse are more appropriate.
C. Strabismus is common in newborns due to the immaturity of eye muscle control and usually resolves as the child develops. This is the most therapeutic response as it provides reassurance based on developmental norms.
D. Calling the primary care provider might be premature unless the nurse identifies a significant concern beyond normal development.

A. Genetic testing must be done for all siblings B. The child should be enrolled in early intervention programs C. Keep the child amongst family members only D. The child will have a short life expectancy

Correct Answer is B

Explanation

A. Genetic testing may be recommended for family members, but it is not a necessity for all siblings unless they are showing symptoms.
B. Early intervention programs are crucial for children with Fragile X syndrome to address developmental delays, speech, and socialization skills.
C. While maintaining family support is important, children with Fragile X syndrome should have social opportunities with others outside the family to help with social development.
D. Children with Fragile X syndrome typically have normal life expectancy, although the condition can lead to intellectual disabilities and developmental delays.

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Actions to Take

Parameters to Monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a new mother who is concerned that her newborn has strabismus. Which of the following statements is a therapeutic response by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a 4-year-old client diagnosed with Fragile X Syndrome. Which information should be included in the teaching plan for the parents?

Correct Answer is B

Explanation

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