Parents of an infant with an inguinal hernia bring their child to the emergency department reporting that the hernia has changed in color to dark purple and child has not had a bowel movement in 24 hours. The nurse obtains a Face, Legs, Activity, Cry, Consolability (FLACC) scale score of 8 on initial assessment. Which action should the nurse prioritize?
Report the assessment to the healthcare provider.
Determine when oral fluids were last taken.
Attempt to reduce the hernia manually.
Prepare to initiate venous access for an intravenous (IV) infusion
The Correct Answer is A
A. Report the assessment to the healthcare provider.
The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.
Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.
B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.
C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.
D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.
A. Report the assessment to the healthcare provider.
The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.
Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.
B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.
C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.
D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Plays "peek-a-boo."
This is a social and cognitive milestone. Infants typically develop social interactions like peek-a-boo around 6-9 months of age. This behavior is normal for a 6-month-old and demonstrates social engagement.
B. Has doubled birth weight.
Infants generally double their birth weight by around 6 months of age. This is a typical growth and developmental milestone, indicating adequate nutrition and growth.
C. Turns head to locate sound.
This is a normal developmental milestone for an infant. By 6 months of age, infants should demonstrate localization of sounds, indicating appropriate auditory and neurological development.
D. Demonstrates startle reflex.
The startle reflex, also known as the Moro reflex, is normal in newborns but typically disappears by 3-6 months of age. If a 6-month-old still exhibits this reflex, it could be a sign of delayed neurological development and might require further evaluation.
Correct Answer is C
Explanation
A. Weight loss can occur in acute glomerulonephritis due to decreased appetite and fluid imbalances, but it is not as immediately concerning as low blood pressure.
B. A positive rapid strep test of the oropharynx suggests streptococcal infection, which can be a cause of acute glomerulonephritis. It's important to report this finding to the healthcare provider, but the low blood pressure is of more immediate concern.
C. Blood pressure 88/50 mm Hg.
Acute glomerulonephritis can lead to various signs and symptoms, including fatigue, facial puffiness, decreased appetite, and dark urine, due to the presence of blood and protein in the urine. However, the drop in blood pressure (88/50 mm Hg) is a significant finding that may suggest potential complications or worsening renal function. Low blood pressure can result from fluid shifts, reduced circulating blood volume, and decreased cardiac output in acute glomerulonephritis. It should be reported to the healthcare provider for further evaluation and management.
D. A maculopapular rash over the trunk of the body is not a typical finding associated with acute glomerulonephritis. While it may be significant for other reasons, it may not be directly related to the child's kidney condition.
Monitoring and addressing blood pressure changes is a crucial aspect of managing acute glomerulonephritis, and the healthcare provider should be informed promptly to assess and address this issue.
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