After administering varicella vaccine to a five-year-old child, which instruction should the nurse provide the child's parent?

Choice A reason: Measuring abdominal circumference is not the first action that the nurse should take. This is because abdominal circumference is not a reliable indicator of bowel obstruction or perforation, which are possible complications of meconium ileus. Measuring abdominal circumference may also delay more urgent interventions, such as fluid resuscitation and decompression.

Choice B reason: Gathering supplies for an intravenous (IV) infusion is the first action that the nurse should take. This is because the infant is at risk of dehydration, electrolyte imbalance, and shock due to vomiting and bowel obstruction. The nurse should prepare to administer IV fluids, antibiotics, and blood products as ordered by the healthcare provider.

Choice C reason: Monitoring strict urinary output is not the first action that the nurse should take. This is because urinary output is not the most sensitive indicator of fluid status in infants, especially those with renal insufficiency or oliguria. Monitoring urinary output may also delay more urgent interventions, such as fluid resuscitation and decompression.

Choice D reason: Preparing for anorectal manometry is not the first action that the nurse should take. This is because anorectal manometry is a diagnostic test that measures the pressure and function of the anal and rectal muscles. It is not indicated for infants with suspected meconium ileus, which is a mechanical obstruction of the bowel by thick and sticky meconium. Preparing for anorectal manometry may also delay more urgent interventions, such as fluid resuscitation and decompression.

Choice A reason: Obtaining a swab of secretions from the penis and urethra is not the appropriate action to take in this situation. This may be done to test for sexually transmitted infections (STIs), such as chlamydia or gonorrhea, that can cause epididymitis, an inflammation of the tube that carries sperm from the testicle. However, epididymitis usually causes gradual pain and swelling, not sudden and severe, and is unlikely to be triggered by a physical activity. Moreover, obtaining a swab may be painful and unnecessary for the adolescent.

Choice B reason: Collecting a sterile urine sample for culture and sensitivity is not the appropriate action to take in this situation. This may be done to test for urinary tract infections (UTIs) or kidney stones that can cause testicular pain. However, UTIs and kidney stones usually cause other symptoms, such as burning or difficulty urinating, blood in the urine, or lower back pain. They are also unlikely to be triggered by a physical activity. Moreover, collecting a urine sample may be difficult and uncomfortable for the adolescent.

Choice C reason: Providing the adolescent with a urinal for urinary hesitancy is not the appropriate action to take in this situation. Urinary hesitancy is the difficulty or delay in starting or maintaining a urine stream. It can be caused by various factors, such as anxiety, medication, prostate problems, or nerve damage. It is not a common symptom of testicular pain and is not related to the cause of the pain. Moreover, providing a urinal may be embarrassing and unnecessary for the adolescent. ⁷

Choice D reason: Reporting the findings immediately to the healthcare provider is the appropriate action to take in this situation. Sudden and severe testicular pain and swelling can be a sign of testicular torsion, a medical emergency that occurs when the testicle twists and cuts off its blood supply. Testicular torsion can be caused by trauma, strenuous exercise, or cold temperature. It can lead to permanent damage or loss of the testicle if not treated promptly. The adolescent needs urgent evaluation and possible surgery to untwist the testicle and restore blood flow.