Which assessment finding would cause the nurse to notify the MD immediately when assessing a 10-month-old child who had emergency reduction for intussusception 10 hours previously?
Axillary temperature of 37.3° C
Mild abdominal pain
BP of 100/54
Currant jelly stools
The Correct Answer is D
Choice A reason: This is incorrect because an axillary temperature of 37.3° C is within the normal range for a 10-month-old child. It does not indicate any infection or complication after the surgery.
Choice B reason: This is incorrect because mild abdominal pain is expected after the surgery and can be managed with analgesics. It does not require immediate notification to the MD.
Choice C reason: This is incorrect because a BP of 100/54 is normal for a 10-month-old child. It does not indicate any shock or hemorrhage after the surgery.
Choice D reason: This is correct because currant jelly stools, which are stools mixed with blood and mucus, are a sign of intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. Currant jelly stools after the surgery indicate that the intussusception has recurred and requires immediate intervention. The nurse should notify the MD and prepare the child for another surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Murmur, tachycardia, and low erythrocyte sedimentation rate are not specific signs of Kawasaki disease. They may indicate other cardiac or inflammatory conditions.
Choice B reason: Abdominal pain, vomiting, and restlessness are not typical signs of Kawasaki disease. They may suggest other gastrointestinal or neurological problems.
Choice C reason: Coarse breath sounds, abnormal ECG, and joint pain are not common signs of Kawasaki disease. They may indicate other respiratory, cardiac, or rheumatic disorders.
Choice D reason: This is the correct choice. Fever, "strawberry tongue" and peeling palms and soles are characteristic signs of Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels. Other signs include red eyes, swollen lips, rash, and swollen lymph nodes.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as aspirin is contraindicated in children under 18 years of age due to the risk of Reye syndrome, a rare but serious condition that affects the liver and brain. The nurse should use other methods to reduce the fever, such as acetaminophen, tepid sponge baths, or cooling blankets.
Choice B reason: This statement is incorrect, as hospital-acquired sepsis is unlikely in a 3-day-old infant, unless the infant was exposed to invasive procedures or devices, such as catheters, ventilators, or surgery. The nurse should consider other sources of infection, such as the maternal genital tract, the umbilical cord, or the skin.
Choice C reason: This statement is incorrect, as blood pressure is not an early indicator of sepsis, but a late sign of shock. The nurse should monitor the infant for other signs of sepsis, such as temperature instability, tachycardia, tachypnea, lethargy, poor feeding, irritability, or hypoglycemia.
Choice D reason: This statement is correct, as the most common cause of sepsis in neonates is vertical transmission from the mother during pregnancy, labor, or delivery. The nurse should obtain a history of the mother's prenatal care, infections, medications, or complications, and assess the infant for any congenital anomalies or risk factors.
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