A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?
Projectile vomiting
Periorbital edema
Stools that contain currant jelly-like mucus
Visible gastric peristaltic waves
The Correct Answer is C
Rationale:
A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.
B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.
C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.
D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Measles, mumps, and rubella (MMR): MMR is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of fetal harm. It should be given at least one month prior to conception or postpartum if immunity is needed.
B. Varicella (VAR): Like MMR, the varicella vaccine is live and should not be administered during pregnancy. Pregnant individuals without evidence of immunity should receive it postpartum to protect against future infections.
C. Tetanus diphtheria and pertussis (Tdap): Tdap is recommended during each pregnancy but typically between 27 and 36 weeks of gestation to maximize passive antibody transfer to the fetus. At 16 weeks, it would not yet be indicated.
D. Inactivated influenza (IV): The inactivated flu vaccine is recommended for all pregnant clients during flu season, regardless of the trimester. It protects both the pregnant individual and the fetus from complications related to influenza infection.
Correct Answer is B
Explanation
Rationale:
A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.
B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.
C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.
D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.
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