Parents of an infant with an inguinal hernia bring their child to the emergency department reporting that the hernia has changed in color to dark purple and child has not had a bowel movement in 24 hours. The nurse obtains a Face, Legs, Activity, Cry, Consolability (FLACC) scale score of 8 on initial assessment. Which action should the nurse prioritize?
Report the assessment to the healthcare provider.
Determine when oral fluids were last taken.
Attempt to reduce the hernia manually.
Prepare to initiate venous access for an intravenous (IV) infusion
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Disposing of the child's brushes, combs, and other hair accessories can be a good practice to prevent reinfestation, but it is not the primary instruction to provide in this case.
B. Taking the child to a hair salon for a shampoo and a shorter haircut is not a necessary or recommended treatment for head lice.
C. Wash the child's bed linens and clothing in hot soapy water.
When a child has head lice, it's important to take measures to prevent the spread of lice to others and to eliminate any potential sources of reinfestation. Washing the child's bed linens and clothing in hot, soapy water is an essential step in this process to kill any lice or nits (lice eggs) that may be present on these items.
D. Rewashing the child's hair following a 24-hour isolation period is not the standard approach for treating head lice with permethrin shampoo. It is important to follow the specific instructions provided with the product and to avoid overuse or misuse of the treatment.
The primary focus should be on treating the child's hair with the appropriate lice treatment (permethrin shampoo) as directed and taking preventive measures such as washing bed linens and clothing to reduce the risk of reinfestation.
Correct Answer is C
Explanation
A. While it's essential to monitor the infant's weight gain and the type of formula taken daily, this information is important for tracking growth and nutrition but is not directly related to the use of liquid multivitamin with fluoride.
B. The newborn's gestational age assessment is typically relevant during the immediate postnatal period and may not be as crucial at 6 months of age.
C. The water source used with supplemental feedings is critical when considering the use of liquid multivitamin with fluoride. Fluoride is often recommended to prevent tooth decay, and it's essential to know the fluoride content in the water source to determine whether additional supplementation is needed. If the water source has adequate fluoride, the infant may not require a fluoride supplement.
D. While the infant's current hemoglobin and hematocrit levels are important for assessing anemia, this assessment is not directly related to the request for a prescription for liquid multivitamin with fluoride. In summary, assessing the water source used for supplemental feedings is crucial to determine the necessity of a fluoride supplement, which is the primary concern in this scenario.
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