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

Answer and Explanation

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.

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.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Regular syringe feedings alone do not necessarily promote rapid weight gain, and their appropriateness depends on the underlying cause of FTT and the healthcare provider's recommendations.

B. Breast milk provides adequate calories for the child.

Breast milk is an excellent source of nutrition for infants, providing essential nutrients and calories needed for healthy growth and development. It is generally well-tolerated and suitable for most infants. Encouraging breastfeeding, especially if the infant is not exclusively breastfed, can be a valuable approach in managing FTT.

C. Fruit juice, particularly in excess, may not be recommended for infants with FTT as it can be high in sugars and low in essential nutrients. It is not a primary intervention for FTT.

D. High-calorie formula can be considered for infants with FTT, but it should be prescribed and monitored by a healthcare provider. Simply using high-calorie formula without proper guidance is not an appropriate intervention.

Breast milk is a valuable and appropriate source of nutrition for infants with FTT, and the nurse should support and encourage its use while monitoring the infant's growth and progress closely.

A. Discontinue the ointment once drainage resolves. B. Remove secretions by wiping toward the opposite eye. C. Use a disposable moist wipe to remove eye crusts. D. Prepare child for blurry vision after ointment application.

Correct Answer is D

Explanation

A. Discontinue the ointment once drainage resolves.The ophthalmic antiinfective ointment should be used for the full prescribed duration, even if symptoms improve, to ensure the infection is completely treated and to prevent recurrence or resistance.

B. Remove secretions by wiping toward the opposite eye.Secretions should be removed by wiping away from the eye, from the inner canthus (near the nose) outward, to prevent spreading infection to the unaffected eye.

C. Use a disposable moist wipe to remove eye crusts.While it is important to keep the eye clean, the primary discharge instruction in this context should focus on the expected side effect of blurry vision.

D. Prepare child for blurry vision after ointment application:Ophthalmic antiinfective ointments can cause temporary blurry vision due to their consistency. Caregivers should be informed about this expected effect and reassured that it is temporary. This helps manage expectations and ensures adherence to the treatment plan.

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Naxlex Comprehensive Predictor Exams

The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?

Correct Answer is B

Explanation

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic antiinfective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?

Correct Answer is D

Explanation

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse Implement to ensure the child's cooperation?

Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

The nurse is caring for an infant with unilateral clubfoot. Which information should the nurse include in parent education about long-term outcomes?