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

Answer and Explanation

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.

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.

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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.

A. Olive-size mass in the epigastric area. B. Stool that consists of mucus and blood. C. Rebound tenderness in the left lower abdominal quadrant. D. Frequent burping accompanied by poor feeding

Correct Answer is A

Explanation

Projectile vomiting in a 5-week-old infant can be indicative of a condition known as pyloric stenosis. Pyloric stenosis is a narrowing of the pylorus, the opening from the stomach to the small intestine. It results in delayed gastric emptying, leading to the forceful, projectile vomiting observed after feedings.

A. An olive-size mass in the epigastric area is a characteristic finding in infants with pyloric stenosis. The hypertrophied pyloric muscle feels like an olive and is often palpable in the upper abdomen.

B. Stool that consists of mucus and blood is not a typical finding associated with pyloric stenosis. This symptom is more suggestive of gastrointestinal issues like infectious colitis or other conditions unrelated to pyloric stenosis.

C. Rebound tenderness in the left lower abdominal quadrant is not a common finding in infants with pyloric stenosis. Rebound tenderness is typically associated with conditions like appendicitis in a different part of the abdomen.

D. Frequent burping accompanied by poor feeding can be a sign of discomfort but is not a specific indicator of pyloric stenosis. Projectile vomiting is a more distinctive symptom associated with this condition.

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Naxlex Comprehensive Predictor Exams

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?

Correct Answer is C

Explanation

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

Correct Answer is A

Explanation

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrates an understanding of the education? (Select all that apply.)