Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

A. Using ibuprofen prophylactically to prevent febrile seizures is not a standard approach and is not generally recommended. The focus should be on managing the child's fever with appropriate fever-reducing medications rather than attempting to prevent febrile seizures with medication.

B. Reassure the parents that febrile seizures decrease as the child grows older.

Febrile seizures are relatively common in young children and are typically associated with rapid increases in body temperature, often due to infections.

The most important information to convey to the parents is that febrile seizures are usually a benign and self-limited condition, and they tend to decrease in frequency and may even resolve as the child grows older. Reassuring parents about the natural course of febrile seizures is vital to alleviate their concerns. However, it's essential to educate them on fever management and when to seek medical attention for their child's febrile seizures.

C. Avoiding excessive visual stimuli is not a standard recommendation for preventing febrile seizures. Febrile seizures are primarily related to fever and not visual stimuli.

D. Providing a sponge bath for temperatures over 100.6° F (38.1° C) can help reduce fever, but it is not directly related to preventing febrile seizures. The main goal in such situations is to manage the fever itself.

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.