What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?

Choice A rationale
Discouraging the client from ambulating is not the best action. While it’s important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis.
Choice B rationale
Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin.
Choice C rationale
Keeping the client’s leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing.
Choice D rationale
Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.

The correct answer is (C) Determine if the toddler is voiding.

Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.

Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.

Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.

Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.