The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided pneumonia to visualize and correct the intussusception, the child passes a currant jelly-like stool.

Which nursing action is the most appropriate?

Measure the abdominal girth.

Notify the practitioner as this is not a typical finding.

Document as an expected finding and plan to move forward with the procedure.

Auscultate for bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.

Choice B reason:

Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.

Choice C reason:

Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.

Choice D reason:

Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.

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Correct Answer is C

Explanation

Choice A reason:

Opioid analgesics are not given as a last resort solely because of the threat of addiction. While the risk of addiction is a concern, opioids are often necessary for managing severe pain, especially in conditions like sickle cell anemia. The American Society of Hematology guidelines emphasize the importance of effective pain management in sickle cell disease, which often includes the use of opioids. The goal is to manage pain effectively while monitoring for signs of misuse or addiction.

Choice B reason:

Opioid analgesics are often ordered and are usually needed for managing severe pain in patients with sickle cell anemia. Pain episodes in sickle cell disease can be extremely severe and debilitating, requiring potent analgesics like morphine for relief. The management of acute vaso-occlusive pain in sickle cell disease often necessitates the use of opioids to provide adequate pain control.

Choice C reason:

Opioid analgesics, when medically indicated and used under proper medical supervision, rarely cause addiction. The risk of addiction is significantly lower when opioids are used appropriately for pain management in a controlled medical setting. The Mayo Clinic highlights that while opioids have addictive properties, their medical use for pain relief, especially in acute settings, is generally safe when monitored by healthcare professionals.

Choice D reason:

Opioid analgesics are not used only if other measures, such as ice packs, are ineffective. While non-pharmacological measures can be part of pain management, opioids are often necessary for managing severe pain episodes in sickle cell disease. The use of opioids is based on the severity of the pain and the clinical judgment of the healthcare provider.

A. Cleansing the suture line, upright position, arm restraints B. Mouth irrigations, prone position, cleansing the suture line C. Frequent oral suction, spoon feed, give them a teething toy D. Arm restraints, postural drainage, mouth irrigations

Correct Answer is A

Explanation

Choice A reason:

Cleansing the suture line, maintaining an upright position, and using arm restraints are crucial aspects of postoperative care for an infant after cleft lip repair. Cleansing the suture line helps prevent infection and promotes healing. Keeping the infant in an upright position reduces the risk of aspiration and helps with breathing. Arm restraints prevent the infant from touching or rubbing the surgical site, which could disrupt the healing process.

Choice B Reason:

Mouth irrigations and a prone position are not recommended for postoperative care after cleft lip repair. Mouth irrigations can be too harsh for the delicate surgical site, and a prone position (lying face down) can increase the risk of aspiration and breathing difficulties. Cleansing the suture line is important, but the other aspects of this choice are not suitable.

Choice C Reason:

Frequent oral suction and spoon feeding are not appropriate for an infant after cleft lip repair. Oral suction can be too aggressive and may damage the surgical site. Spoon feeding is not recommended as it can put pressure on the healing lip. Giving a teething toy is also not advisable as it can cause the infant to put objects in their mouth, potentially harming the surgical site.

Choice D Reason:

Arm restraints are indeed necessary to prevent the infant from touching the surgical site. However, postural drainage and mouth irrigations are not suitable for postoperative care after cleft lip repair. Postural drainage is not relevant to this condition, and mouth irrigations can be too harsh for the healing tissue.

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The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided pneumonia to visualize and correct the intussusception, the child passes a currant jelly-like stool. Which nursing action is the most appropriate?

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The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided pneumonia to visualize and correct the intussusception, the child passes a currant jelly-like stool.

Which nursing action is the most appropriate?