A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?

A. Projectile vomiting

Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents.

B. Metabolic acidosis

Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly.

C. Effortless regurgitation

Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents.

D. Distended abdomen

A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.

A. Maintain seizure precautions:

While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions.

B. Document intake and output:

Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications.

C. Administer antibiotics when available:

Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death.

D. Reduce environmental stimuli:

While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.