A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Superficial palpation

Auscultation

Inspection

Deep palpation

Answer and Explanation

The Correct Answer is C, B, A, D

Inspection: This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation: After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation: This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary): Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort: Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds: Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression: Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

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Correct Answer is D

Explanation

A. "I’m glad my child will have normal bowel movements now.": This statement indicates a misunderstanding of Hirschsprung disease. Surgery for Hirschsprung disease involves removing the portion of the large intestine affected by the condition, which often results in a temporary or permanent colostomy. While surgery aims to improve bowel function, it may not immediately result in normal bowel movements, especially if complications arise or additional surgeries are needed.
B. "I want to learn how to use my child's feeding tube as soon as possible.": This statement suggests a focus on enteral nutrition rather than the surgical management of Hirschsprung disease. While enteral feeding may be necessary for some children with Hirschsprung disease, the primary focus of initial surgery is to remove the affected portion of the large intestine and create an ostomy if needed, rather than addressing feeding tube use.
C. "I want to learn how to empty my child's urinary catheter bag.": This statement pertains to urinary catheter care rather than the surgical management of Hirschsprung disease. While urinary catheters may be used during surgery and recovery, they are not directly related to the treatment of Hirschsprung disease itself.
D. "I'm glad that my child's ostomy is only temporary": This statement demonstrates an understanding of the surgical management of Hirschsprung disease. Many children with Hirschsprung disease require surgery to remove the affected portion of the large intestine and create an ostomy, which may be temporary or permanent depending on the extent of the disease and the child's response to treatment. Recognizing that the ostomy is temporary indicates an understanding of the potential outcomes of surgery and the possibility of eventual bowel anastomosis.

A. Administer ibuprofen as needed for pein B. Encourage the parents to rock the infant C. Offer the infant a pacifier. D. Position the infant on her abdomen

Correct Answer is B

Explanation

Rationale:

A) Administer ibuprofen as needed for pain: Ibuprofen is not typically recommended for pain relief in infants under 6 months old due to the risk of adverse effects, such as gastrointestinal irritation and renal impairment. Additionally, surgical repair of a cleft lip is not typically associated with severe postoperative pain requiring ibuprofen in infants.

B) Encourage the parents to rock the infant: This is the correct intervention. Rocking or gentle movement can provide comfort to infants postoperatively and may help soothe them. It can also promote bonding between the infant and parents, which is important for emotional support during the recovery period.

C) Offer the infant a pacifier: Pacifiers can be soothing for infants and may help provide non-nutritive sucking comfort. However, it's essential to ensure that the pacifier does not interfere with wound healing or exacerbate discomfort related to the cleft lip repair. Therefore, while offering a pacifier may be appropriate, it should be done with caution and under the guidance of the surgical team.

D) Position the infant on her abdomen: Placing the infant on her abdomen (prone position) is not recommended postoperatively, especially after cleft lip repair surgery. The supine position is typically preferred to reduce the risk of aspiration and ensure adequate airway patency. Additionally, the prone position may put pressure on the surgical site and cause discomfort.

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A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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