Exhibits

A nurse is collecting data from an adolescent who has bacterial pneumonia. Which of the following findings is the priority for the nurse to report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for Correct Choices:

• Intussusception: The toddler's sudden onset of crying, drawing knees to the chest, and high-pitched cry are classic signs of intussusception. The "red jelly" stool (currant jelly stool) is also a hallmark symptom of this condition.
• Reinforce teaching with the guardian about hydrostatic reduction: Hydrostatic reduction is the treatment for intussusception, where a contrast material is used to reduce the telescoped bowel. It's an important intervention that should be discussed with the guardian.
• Palpate the toddler's abdomen for a mass in the upper quadrant: A palpable abdominal mass is a classic sign of intussusception, and the nurse should assess for this to help confirm the diagnosis.
• Abdominal pain: Monitoring abdominal pain is essential because it can be a significant indicator of worsening intussusception or any complications. The child is showing signs of severe pain, so it needs to be closely watched.
• Stool consistency: The "red jelly" stool is a key finding of intussusception, and the nurse should continue to monitor for this, as it is a clear indicator of bowel obstruction.

Rationale for Incorrect Choices:

• Prepare the toddler for an upper endoscopy with possible biopsy : An upper endoscopy with biopsy is used to assess gastrointestinal conditions like Celiac disease or gastroesophageal reflux. Intussusception is diagnosed through imaging techniques like ultrasound or a contrast enema, not an upper endoscopy.
• Request a prescription for a fat-soluble vitamin supplement: Vitamin supplements are more relevant to conditions like Celiac disease or other chronic malabsorption syndromes.
• Obtain a prescription for blood transglutaminase antibody testing: This test is relevant for diagnosing Celiac disease but is not needed for diagnosing intussusception, which requires imaging and clinical assessment for bowel obstruction.
• Gastroesophageal reflux: Gastroesophageal reflux does not typically present with the acute abdominal pain, "red jelly" stool, or the high-pitched crying observed in this toddler. It's more of a chronic condition associated with spitting up or regurgitation.
• Celiac disease: Celiac disease typically presents with gastrointestinal issues like diarrhea, abdominal distension, and failure to thrive, rather than acute symptoms like crying and "red jelly" stools.
• Gastroenteritis: While gastroenteritis may present with vomiting, diarrhea, and irritability, it does not explain the specific findings of a high-pitched cry, drawing knees to the chest, or the characteristic stool.
• Bone mineral densit: Bone mineral density is relevant to conditions like osteoporosis or rickets but is not related to intussusception. The focus here should be on monitoring gastrointestinal symptoms, particularly abdominal pain and stool consistency, not bone health.
• Sleep pattern: While sleep pattern can be affected by various conditions, it is not a primary concern in the management of intussusception. The toddler's acute symptoms (pain, vomiting, stool changes) should take precedence over monitoring sleep.
• Urine specific gravity: Urine specific gravity is typically monitored for dehydration or kidney function, but intussusception is not primarily associated with these issues.
• Request a prescription for blood transglutaminase antibody testing: This test is relevant for diagnosing Celiac disease but is not needed for diagnosing intussusception, which requires imaging and clinical assessment for bowel obstruction.

A. Oral rehydration solution: Oral rehydration solutions (ORS) are recommended to replace lost fluids and electrolytes during episodes of diarrhea. They help prevent dehydration, which is a common complication in infants with diarrhea.
B. Breast milk: Breast milk is the best option for a breastfed infant during an episode of diarrhea. It provides essential nutrients and hydration, as well as antibodies that can help protect against infections and improve recovery.
C. Chicken broth: Chicken broth is not recommended for infants under 6 months old due to its high sodium content and lack of essential nutrients for young infants. It could potentially cause electrolyte imbalances.
D. Clear soda: Clear soda should be avoided, as it contains high levels of sugar and can worsen dehydration. It does not provide the necessary electrolytes and fluids needed to rehydrate an infant.
E. Apple juice: Apple juice is not recommended for infants with diarrhea, as it can contribute to diarrhea due to its high sugar content, particularly fructose, which can draw water into the intestines and worsen dehydration.