A nurse is caring for a toddler who has intussusception.

Which of the following manifestations should the nurse expect?

The correct answer is (C) Determine if the toddler is voiding.

Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.

Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.

Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.

Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

• Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
• Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
• Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
• Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.