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 C
Explanation
A. Disposing of the child's brushes, combs, and other hair accessories can be a good practice to prevent reinfestation, but it is not the primary instruction to provide in this case.
B. Taking the child to a hair salon for a shampoo and a shorter haircut is not a necessary or recommended treatment for head lice.
C. Wash the child's bed linens and clothing in hot soapy water.
When a child has head lice, it's important to take measures to prevent the spread of lice to others and to eliminate any potential sources of reinfestation. Washing the child's bed linens and clothing in hot, soapy water is an essential step in this process to kill any lice or nits (lice eggs) that may be present on these items.
D. Rewashing the child's hair following a 24-hour isolation period is not the standard approach for treating head lice with permethrin shampoo. It is important to follow the specific instructions provided with the product and to avoid overuse or misuse of the treatment.
The primary focus should be on treating the child's hair with the appropriate lice treatment (permethrin shampoo) as directed and taking preventive measures such as washing bed linens and clothing to reduce the risk of reinfestation.
Correct Answer is ["A","D","E"]
Explanation
To help the parents decrease their anxiety, the nurse can:
A. Provide the parents with ideas about how to make their child feel better after the procedure. This can help reassure the parents that they can support their child during the recovery process.
D. Find a comfortable area that the parents can wait that is close to the procedure area. Being close to the procedure area allows the parents to stay informed and feel more connected to their child during the procedure.
E. Do not give any specifics on the amount of time the procedure will take. Providing a specific time may increase anxiety, so it's often better to provide a general idea of the timeframe.
Option B is not appropriate because stating that the procedure is 100% effective and safe may not be accurate and could lead to false expectations.
Option C is not appropriate because limiting visitation based on the parents' anxiety is not typically recommended. Supportive presence is generally encouraged for both the child and parents.
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