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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as asking about the child's contacts over the last three weeks can help the nurse identify the possible source of infection and the risk of transmission. Rubella is a viral infection that spreads through respiratory droplets or direct contact with an infected person. The incubation period of rubella is 14 to 21 days, meaning that the child could have been exposed to the virus up to three weeks before developing symptoms.
Choice B reason: This statement is incorrect, as asking about the child's immunizations is not the most effective way to determine how the child was exposed to the virus. Although immunization can prevent rubella infection, it is not 100% effective, and some children may still get the disease despite being vaccinated. The nurse should also consider other factors, such as the child's medical history, travel history, and exposure to other people with rash or fever.
Choice C reason: This statement is incorrect, as asking about the medications given to the child is not the most effective way to determine how the child was exposed to the virus. Medications can help relieve the symptoms of rubella, such as fever, rash, or joint pain, but they do not affect the transmission or the course of the infection. The nurse should focus on the epidemiological aspects of the disease, such as the mode of transmission, the incubation period, and the contagious period.
Choice D reason: This statement is incorrect, as asking about the onset of the rash is not the most effective way to determine how the child was exposed to the virus. The rash of rubella usually appears 14 to 17 days after exposure, and lasts for about three days. However, the child can be contagious from seven days before to seven days after the rash appears, meaning that the child could have been exposed to the virus up to four weeks before or after the rash. The nurse should ask about the child's contacts during this period, not just the rash.
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