An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?
Gather supplies for an Intravenous (IV) infusion.
Measure abdominal circumference.
Prepare for anorectal manometry.
Monitor strict urinary output
The Correct Answer is B
A. Gathering supplies for an Intravenous (IV) infusion may be necessary if the infant becomes dehydrated or requires fluid resuscitation, but it is not the first action to take when there are concerns about a potential intestinal obstruction.
B. Measure abdominal circumference.
The infant's failure to pass meconium stool and the vomiting of bilious secretions are concerning signs that could indicate an obstruction in the gastrointestinal tract. Measuring the abdominal circumference is an essential initial assessment to determine if there is abdominal distension or enlargement, which can be a sign of an obstruction. Abdominal distention can help the healthcare provider assess the severity of the issue and make informed decisions regarding further diagnostic tests and interventions.
C. Preparing for anorectal manometry is not the first step in this situation. Anorectal manometry is a diagnostic test that may be considered later, depending on the findings and the healthcare provider's assessment.
D. Monitoring strict urinary output is not the primary concern in this case; the focus should be on assessing the infant's gastrointestinal status and potential bowel obstruction.
The nurse should promptly measure the infant's abdominal circumference to assess for signs of abdominal distension or obstruction and then communicate these findings to the healthcare provider for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answers are A, D, E.
Before the cardiac catheterization for a 3-year-old with a history of ventricular septal defect, the nurse's focused assessment should include the following:
A. Determine when the child last ate: Knowing when the child last ate is important because the procedure may require fasting, and the nurse needs to ensure that the child has adhered to the fasting guidelines.
D. Locate and mark the pedal pulses: Locating and marking the pedal pulses is essential to establish a baseline for assessing peripheral circulation, especially given the history of ventricular septal defect.
E. Obtain a history of allergic reactions: Obtaining a history of allergic reactions is important to ensure that there are no allergies or sensitivities that could impact the procedure or the use of any contrast materials during the cardiac catheterization.
The other options are not necessary components of the focused assessment in preparation for the cardiac catheterization:
B. Measure the child's height and weight: Measuring height and weight may be done at some point but is not a priority in the immediate pre-procedural assessment.
C. Perform a mini-mental exam on the child: A mini-mental exam may not be applicable or necessary in the pre-catheterization assessment of a 3-year-old.
F. Document lying, sitting, and standing blood pressures: Blood pressure variations in different positions are typically not relevant for this type of procedure, and it may not be practical or necessary for a 3-year-old.
Correct Answer is B
Explanation
The intervention the nurse should implement when the child screams and tries to hide behind the parent, dropping a stuffed toy during the collection of the medical history is B.
A. Ignoring the child's behavior and directing questions only to the parent may further distress the child and make them more anxious. It's important to acknowledge the child's feelings and create a supportive environment.
B. Include the child's toy in the collection of information.
Children can become anxious or fearful in healthcare settings, and using strategies to make them feel more comfortable and involved can help build trust. By including the child's toy in the collection of information, the nurse can create a more relaxed and child-friendly atmosphere. This can help the child feel less threatened and more willing to participate in the history-taking process.
C. Documenting interactions between the parent and the child is important for the medical record, but it doesn't address the child's current distress.
D. Obtaining essential information as quickly as possible, without considering the child's comfort and engagement, may not yield the best history and could potentially create resistance and fear in the child.
Therefore, including the child's toy in the process, making the interaction child-friendly, and acknowledging the child's comfort are essential to improve the experience and gather necessary information in a more relaxed atmosphere.
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