A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Rationale:

• Temperature: The child’s temperature is 37.4°C (99.3°F), which is mildly elevated. Crohn’s disease typically causes intermittent fever during flare-ups. Appendicitis often presents with a higher fever in later stages. Intussusception can cause low-grade fever due to bowel inflammation, making it the most consistent with this finding.
• Vomiting: Vomiting is uncommon in Crohn’s disease unless there’s obstruction or severe disease. In appendicitis, vomiting usually follows the onset of pain and is related to peritoneal irritation. Intussusception often involves vomiting early due to intermittent bowel obstruction, making it consistent with this client’s symptoms.
• Abdominal findings: Crohn’s disease rarely produces a palpable abdominal mass or sudden distension. Appendicitis can cause right-sided tenderness and decreased bowel sounds but does not typically involve a mass. Intussusception often presents with a distended abdomen, hypoactive bowel sounds, and a sausage-shaped mass in the right upper quadrant, as described.
• Stool: Crohn’s disease can lead to bloody, mucus-filled stools due to ulceration in the intestinal lining. Appendicitis does not typically alter stool characteristics unless perforation occurs. Intussusception is well known for producing “currant jelly” stools, composed of blood and mucus, aligning with this child’s bowel movement description.
• Pain rating: A FLACC score of 5 indicates moderate pain. Crohn’s pain tends to be chronic and crampy rather than episodic. Appendicitis pain worsens over time and becomes localized, typically in the right lower quadrant. Intussusception causes intermittent, severe abdominal pain with sudden relief, matching the child’s pain episodes and behavior.

Rationale:

A. Hypertension: Dehydration in infants typically causes hypotension, not hypertension, due to reduced circulating volume and poor perfusion as fluid loss progresses.

B. Decreased temperature: While temperature may fluctuate in dehydration, fever is more common due to infection-related fluid loss. A decreased temperature is not a consistent sign.

C. Oliguria: Decreased urine output is a key indicator of dehydration in infants. The kidneys conserve water during hypovolemia, resulting in oliguria (less than 1 mL/kg/hr).

D. Bulging anterior fontanel: A bulging fontanel usually indicates increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel in infants.