An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Gather supplies for an Intravenous (IV) infusion.

Measure abdominal circumference.

Prepare for anorectal manometry.

Monitor strict urinary output

Answer and Explanation

The Correct Answer is B

A. Gathering supplies for an Intravenous (IV) infusion may be necessary if the infant becomes dehydrated or requires fluid resuscitation, but it is not the first action to take when there are concerns about a potential intestinal obstruction.

B. Measure abdominal circumference.

The infant's failure to pass meconium stool and the vomiting of bilious secretions are concerning signs that could indicate an obstruction in the gastrointestinal tract. Measuring the abdominal circumference is an essential initial assessment to determine if there is abdominal distension or enlargement, which can be a sign of an obstruction. Abdominal distention can help the healthcare provider assess the severity of the issue and make informed decisions regarding further diagnostic tests and interventions.

C. Preparing for anorectal manometry is not the first step in this situation. Anorectal manometry is a diagnostic test that may be considered later, depending on the findings and the healthcare provider's assessment.

D. Monitoring strict urinary output is not the primary concern in this case; the focus should be on assessing the infant's gastrointestinal status and potential bowel obstruction.

The nurse should promptly measure the infant's abdominal circumference to assess for signs of abdominal distension or obstruction and then communicate these findings to the healthcare provider for further evaluation and intervention.

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Correct Answer is C

Explanation

A. Weight loss can occur in acute glomerulonephritis due to decreased appetite and fluid imbalances, but it is not as immediately concerning as low blood pressure.

B. A positive rapid strep test of the oropharynx suggests streptococcal infection, which can be a cause of acute glomerulonephritis. It's important to report this finding to the healthcare provider, but the low blood pressure is of more immediate concern.

C. Blood pressure 88/50 mm Hg.

Acute glomerulonephritis can lead to various signs and symptoms, including fatigue, facial puffiness, decreased appetite, and dark urine, due to the presence of blood and protein in the urine. However, the drop in blood pressure (88/50 mm Hg) is a significant finding that may suggest potential complications or worsening renal function. Low blood pressure can result from fluid shifts, reduced circulating blood volume, and decreased cardiac output in acute glomerulonephritis. It should be reported to the healthcare provider for further evaluation and management.

D. A maculopapular rash over the trunk of the body is not a typical finding associated with acute glomerulonephritis. While it may be significant for other reasons, it may not be directly related to the child's kidney condition.

Monitoring and addressing blood pressure changes is a crucial aspect of managing acute glomerulonephritis, and the healthcare provider should be informed promptly to assess and address this issue.

A. Ignore the child's behavior, directing questions to a parent. B. Include the child's toy in the collection of information. C. Document interactions between the parent and the child. D. btain the essential information as quickly as possible.

Correct Answer is B

Explanation

The intervention the nurse should implement when the child screams and tries to hide behind the parent, dropping a stuffed toy during the collection of the medical history is B.

A. Ignoring the child's behavior and directing questions only to the parent may further distress the child and make them more anxious. It's important to acknowledge the child's feelings and create a supportive environment.

B. Include the child's toy in the collection of information.

Children can become anxious or fearful in healthcare settings, and using strategies to make them feel more comfortable and involved can help build trust. By including the child's toy in the collection of information, the nurse can create a more relaxed and child-friendly atmosphere. This can help the child feel less threatened and more willing to participate in the history-taking process.

C. Documenting interactions between the parent and the child is important for the medical record, but it doesn't address the child's current distress.

D. Obtaining essential information as quickly as possible, without considering the child's comfort and engagement, may not yield the best history and could potentially create resistance and fear in the child.

Therefore, including the child's toy in the process, making the interaction child-friendly, and acknowledging the child's comfort are essential to improve the experience and gather necessary information in a more relaxed atmosphere.

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An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?

Correct Answer is B

Explanation

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