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. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.
B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.
C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.
D Correction will require serial casting.
Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.
Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.
Correct Answer is C
Explanation
A. While it's essential to monitor the infant's weight gain and the type of formula taken daily, this information is important for tracking growth and nutrition but is not directly related to the use of liquid multivitamin with fluoride.
B. The newborn's gestational age assessment is typically relevant during the immediate postnatal period and may not be as crucial at 6 months of age.
C. The water source used with supplemental feedings is critical when considering the use of liquid multivitamin with fluoride. Fluoride is often recommended to prevent tooth decay, and it's essential to know the fluoride content in the water source to determine whether additional supplementation is needed. If the water source has adequate fluoride, the infant may not require a fluoride supplement.
D. While the infant's current hemoglobin and hematocrit levels are important for assessing anemia, this assessment is not directly related to the request for a prescription for liquid multivitamin with fluoride. In summary, assessing the water source used for supplemental feedings is crucial to determine the necessity of a fluoride supplement, which is the primary concern in this scenario.
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