Which assessment finding would cause the nurse to notify the MD immediately when assessing a 10-month-old child who had emergency reduction for intussusception 10 hours previously?

Axillary temperature of 37.3° C

Mild abdominal pain

BP of 100/54

Currant jelly stools

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because an axillary temperature of 37.3° C is within the normal range for a 10-month-old child. It does not indicate any infection or complication after the surgery.

Choice B reason: This is incorrect because mild abdominal pain is expected after the surgery and can be managed with analgesics. It does not require immediate notification to the MD.

Choice C reason: This is incorrect because a BP of 100/54 is normal for a 10-month-old child. It does not indicate any shock or hemorrhage after the surgery.

Choice D reason: This is correct because currant jelly stools, which are stools mixed with blood and mucus, are a sign of intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. Currant jelly stools after the surgery indicate that the intussusception has recurred and requires immediate intervention. The nurse should notify the MD and prepare the child for another surgery.

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Correct Answer is D

Explanation

Choice A reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause is unknown, but it may be related to genetic, environmental, or hormonal factors.

Choice B reason: Slow feeding will not be sufficient to manage hypertrophic pyloric stenosis. The infant will have persistent vomiting, dehydration, and weight loss due to the obstruction of the pylorus.

Choice C reason: Dietary restrictions will not be effective for hypertrophic pyloric stenosis. The infant will not be able to tolerate any oral intake until the pylorus is surgically corrected.

Choice D reason: Surgery will be necessary to treat hypertrophic pyloric stenosis. The surgery is called pyloromyotomy, which involves cutting the thickened muscle of the pylorus to allow the stomach to empty into the duodenum.

A. Watch for signs of cyanosis and administer high dose steroids B. Obtain blood cultures, administer high dose antibiotics, assess for cardiac decompensation C. Start high dose antibiotics, obtain serial blood cultures, put the child on high flow oxygen D. Obtain CBC, CXR and start child on high dose aspirin

Correct Answer is B

Explanation

Choice A reason: This is not a good choice. Watching for signs of cyanosis and administering high dose steroids are not the first steps in managing infective endocarditis. Cyanosis is a late sign of hypoxia and steroids are not indicated for this condition.

Choice B reason: This is the correct choice. Obtaining blood cultures, administering high dose antibiotics, and assessing for cardiac decompensation are the priority interventions for a child with infective endocarditis. Blood cultures are needed to identify the causative organism and guide antibiotic therapy. High dose antibiotics are needed to eradicate the infection and prevent further damage to the heart valves. Cardiac decompensation is a serious complication of infective endocarditis that can lead to heart failure and shock.

Choice C reason: This is not a good choice. Starting high dose antibiotics, obtaining serial blood cultures, and putting the child on high flow oxygen are not the best order of management for infective endocarditis. Blood cultures should be obtained before starting antibiotics to avoid false negative results. High flow oxygen may not be necessary unless the child has signs of hypoxia or respiratory distress.

Choice D reason: This is not a good choice. Obtaining CBC, CXR and starting child on high dose aspirin are not the first steps in managing infective endocarditis. CBC and CXR are useful tests to monitor the infection and the cardiac function, but they are not as urgent as blood cultures. High dose aspirin is not recommended for infective endocarditis as it can increase the risk of bleeding.

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Which assessment finding would cause the nurse to notify the MD immediately when assessing a 10-month-old child who had emergency reduction for intussusception 10 hours previously?

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