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 A
Explanation
Choice A reason:
Oral rehydration solution (ORS) is the first-line treatment for children with acute diarrhea and moderate dehydration. ORS contains a precise balance of electrolytes and glucose, which helps to rehydrate the child effectively by promoting the absorption of water and electrolytes in the intestines. The World Health Organization (WHO) and the American Academy of Pediatrics recommend ORS as the preferred treatment for dehydration caused by diarrhea. It is effective, easy to administer, and can be given at home or in a healthcare setting.
Choice B reason:
Antidiarrheal medications such as paregoric are not recommended for children with acute diarrhea. These medications can slow down the movement of the intestines, which may prolong the infection and increase the risk of complications. Additionally, they do not address the underlying cause of dehydration. The primary goal in managing acute diarrhea is to rehydrate the child, which is best achieved with ORS.
Choice C reason:
Clear liquids, such as water, broth, or diluted fruit juices, can be used to provide some hydration, but they do not contain the necessary electrolytes to effectively treat moderate dehydration. Clear liquids alone are not sufficient to replace the lost electrolytes and fluids caused by diarrhea. ORS is specifically formulated to address these needs and is more effective in rehydrating the child.
Choice D reason:
Adsorbents, such as kaolin and pectin, are not recommended for the treatment of acute diarrhea in children. These substances can bind to the contents of the intestines and may reduce the frequency of stools, but they do not address the underlying dehydration. The primary focus should be on rehydration with ORS, which provides the necessary electrolytes and fluids to restore the child’s hydration status.
Correct Answer is A
Explanation
Choice A reason:
Wearing cotton underpants is recommended to prevent urinary tract infections (UTIs) in young girls. Cotton is a breathable fabric that allows air to circulate, reducing moisture and creating an environment less conducive to bacterial growth. This helps to keep the genital area dry and clean, which is important in preventing UTIs.
Choice B reason:
Limiting trips to the bathroom is not recommended for preventing UTIs. In fact, it is important for young girls to urinate frequently to flush out bacteria from the urinary tract. Holding urine for extended periods can increase the risk of bacterial growth and infection. Therefore, encouraging regular bathroom trips is a better practice for preventing UTIs.
Choice C reason:
Decreasing salt intake is not directly related to preventing UTIs. While a healthy diet is important for overall health, there is no specific evidence linking salt intake to the prevention of urinary tract infections. The focus should be on practices that directly reduce the risk of bacterial growth and infection in the urinary tract.
Choice D reason:
Soaking in a bathtub, especially with bubble baths or perfumed soaps, can increase the risk of UTIs. These substances can irritate the urethra and create an environment conducive to bacterial growth. It is better to avoid prolonged baths with such products and instead opt for quick showers to maintain hygiene without increasing the risk of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.