The nurse is caring for a child with chronic kidney disease who is experiencing renal osteodystrophy. Which outcome should the nurse explain to the parents about the sequela for their child with renal osteodystrophy?

Choice A reason: Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.

Choice B reason: Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.

Choice C reason: Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.

Choice D reason: Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.

Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.

Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.

Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.

Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.