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
Explanation
A. Osteosarcoma.
The presentation of localized knee pain, especially when it worsens at night, along with swelling, tenderness, and the presence of radial ossification in the soft tissues, raises concerns about the possibility of osteosarcoma. Osteosarcoma is a malignant bone tumor that commonly occurs in the long bones of the body, such as the femur, and often presents with these clinical features.
B. Rhabdomyolysis is a condition that results from the breakdown of muscle tissue and typically presents with symptoms such as muscle pain, weakness, and dark urine due to the release of muscle proteins into the bloodstream. It is not the likely cause of the findings described.
C. Growing pains are typically characterized by intermittent, mild, and diffuse musculoskeletal pain and discomfort in children and adolescents. They do not typically involve localized knee pain, swelling, or tenderness.
D. Hemosiderosis refers to the accumulation of iron in the body and is not typically associated with the described findings or symptoms.
Correct Answer is C
Explanation
A. Administering pain medication based on the FACES pain scale is not the most relevant intervention in the preoperative period for a Wilms' tumor. Pain management may be addressed postoperatively, as needed.
B. Including the prone position in the every 2-hour turning schedule may not be the most appropriate intervention, as it may not be suitable for an infant with a Wilms' tumor, considering the location and potential size of the tumor.
C. Careful bathing and handling that avoids abdominal manipulation.
Wilms' tumor, also known as nephroblastoma, is a pediatric kidney cancer. Prior to surgery, it's crucial to handle the infant with care and avoid any abdominal manipulation to prevent any further complications or disruption to the tumor. This involves gentle handling and avoiding activities that may put pressure on the tumor or cause discomfort to the infant.
D. Giving antiemetic medications to prevent nausea and vomiting is a potential intervention, but it may be more relevant in the postoperative period, and its necessity would depend on the infant's individual condition and the surgical plan.
The priority during the preoperative period for an infant with a Wilms' tumor is to handle the infant carefully and avoid any actions that could exacerbate the condition or cause discomfort. The specific surgical plan and other preoperative preparations would be determined by the healthcare provider.
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