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 D
Explanation
A. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.
B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.
C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.
D Correction will require serial casting.
Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.
Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.
Correct Answer is B
Explanation
A. Surgery should be done by one month to prevent bladder infections. This statement is not accurate. While early surgery is generally recommended, the one-month timeframe is not a strict rule. The primary reason for early correction is to improve the cosmetic appearance of the penis, but it is not primarily aimed at preventing bladder infections.
B. Repair should be done before the child is potty-trained.
Hypospadias is a congenital condition where the opening of the urethra is on the underside of the penis rather than at the tip. Surgical correction is typically recommended, and the timing of the surgery is an important consideration.
C. The urethral repair should be done after sexual maturity. This statement is incorrect. Delaying the repair until sexual maturity is not the standard approach. In fact, earlier surgical correction is often recommended to ensure proper urinary function and to avoid potential psychological and social issues in the child.
D. Delaying the repair until school age reduces castration fears. This statement is not supported by current medical practice. Delaying the repair until school age can lead to psychosocial issues, as children may become more self-aware of their condition and experience teasing or psychological distress.
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