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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Peanuts are not recommended for infants, especially those under one year of age, due to the risk of choking and potential allergies. Additionally, peanuts are not a significant source of iron and would not be effective in preventing iron deficiency anemia in infants. Therefore, this choice is not appropriate for preventing iron deficiency anemia in a 6-month-old infant.
Choice B reason:
Iron (ferrous sulfate) tablets are not typically recommended for infants unless prescribed by a healthcare provider. Infants who are exclusively breastfed or partially breastfed should receive iron supplementation starting at 4-6 months of age, but this is usually in the form of liquid drops rather than tablets. It is important to follow the guidance of a healthcare provider when administering iron supplements to infants.
Choice C reason:
Sautéed liver is a rich source of iron, but it is not suitable for a 6-month-old infant. Introducing solid foods to infants should be done gradually, starting with iron-fortified cereals and pureed fruits and vegetables. Liver can be introduced later as part of a balanced diet, but it is not the first choice for preventing iron deficiency anemia in a young infant.
Choice D reason:
Iron-fortified baby cereal is the recommended choice for preventing iron deficiency anemia in a 6-month-old infant who is still breastfeeding. These cereals are specifically designed to provide the necessary iron that infants need as they transition to solid foods. Starting with iron-fortified cereals helps ensure that the infant receives adequate iron to support healthy growth and development.
Correct Answer is D
Explanation
The correct answer is d. Frequent serial casting is tried first
Choice A reason:
Infants do not outgrow clubfoot on their own. Without treatment, the condition can lead to significant disability and difficulty walking. Early intervention is crucial to correct the deformity and ensure proper foot function.
Choice B Reason:
Surgical intervention is not the first line of treatment for mild cases of clubfoot. Surgery is typically reserved for severe cases or when nonsurgical methods, such as casting, have failed. The goal is to correct the foot’s position using less invasive methods whenever possible.
Choice C Reason:
Traction with foot manipulation is not a standard treatment for clubfoot. The primary nonsurgical treatment involves the Ponseti method, which includes gentle manipulation and serial casting to gradually correct the foot’s position.
Choice D Reason:
Frequent serial casting, known as the Ponseti method, is the first line of treatment for clubfoot. This method involves weekly manipulation and casting of the foot to gradually move it into the correct position. It is highly effective and is the preferred initial treatment for most cases of clubfoot.
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