A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confirm the diagnosis of dehydration?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Analysis of serum electrolytes. Dehydration in infants can lead to serious complications, and the assessment of serum electrolytes is crucial in confirming the diagnosis. When an infant presents with vomiting, diarrhea, fussiness, sunken fontanel, and absence of tears, these are all signs of dehydration. Serum electrolyte levels, such as sodium and potassium, can indicate the degree of dehydration and guide the appropriate treatment. Option A) Urinalysis obtained by bagged specimen is incorrect as it does not directly assess the electrolyte imbalance associated with dehydration. Option B) Urinalysis obtained by sterile catheterization is also incorrect as it focuses on urine analysis rather than serum electrolytes. Option D) Analysis of cerebrospinal fluid is unrelated to diagnosing dehydration in this case. Educationally, understanding the signs and symptoms of dehydration in infants is crucial for nurses and healthcare providers to provide timely and appropriate interventions. Knowing which diagnostic tests are most relevant in such situations can help in effective patient management and prevent further complications. By emphasizing the importance of monitoring electrolyte levels in dehydrated infants, healthcare professionals can improve outcomes and ensure safe and quality care for pediatric patients.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is Option C: Immediately obtain all vital signs with a quick head-to-toe assessment. This response is the most appropriate because the infant is presenting with concerning symptoms such as mucus and bloody diarrhea, irritability, and a distended abdomen. These signs could indicate a serious condition like Hirschsprung disease, which requires prompt evaluation and intervention. Option A is incorrect because dismissing these symptoms as common or expected could delay necessary medical attention. Option B is also incorrect as there is no indication of a cardiac arrest situation based on the symptoms described. Option D is not the most immediate or comprehensive action needed in this urgent situation. From an educational perspective, this question assesses the nurse's ability to prioritize and respond to urgent pediatric gastrointestinal symptoms. Understanding the significance of these symptoms and the need for rapid assessment and intervention is crucial in providing safe and effective care to pediatric patients. This scenario highlights the importance of recognizing red flag symptoms in infants and taking prompt action to ensure their well-being.

Correct Answer: C

Rationale: The correct answer is option C: "The enema will help confirm the diagnosis and has a good chance of reducing the intussusception." This response is the most appropriate because an enema is a common diagnostic and therapeutic intervention for intussusception in infants. The purpose of the enema in this case is to both confirm the diagnosis by visualizing the telescoping of the bowel loops and to potentially reduce the intussusception by hydrostatic pressure or air insufflation, thereby resolving the obstruction. Option A is incorrect because while an enema can confirm the diagnosis, it is not primarily used for this purpose and does not directly imply the need for surgery. Option B is incorrect because enemas are not typically used to fix intussusception definitively, and surgery is often required for resolution. Option D is incorrect as it suggests a more definitive resolution than enemas typically provide and does not accurately portray the likelihood of recurrence. Educationally, it is important for nurses to understand the rationale behind diagnostic and therapeutic interventions to provide accurate information to patients and their families, as well as to ensure safe and effective care for the pediatric population. Understanding the purpose and potential outcomes of procedures like enemas in the context of specific conditions like intussusception is crucial for pediatric nursing practice.

Correct Answer: B

Rationale: The correct answer is B) Administer intravenous fluids and antibiotics. In the pre-operative period for a newborn with tracheoesophageal fistula, administering intravenous fluids and antibiotics is essential to prevent infection and maintain hydration. Surgery on the gastrointestinal system poses a risk of contamination, making antibiotic prophylaxis crucial. Intravenous fluids help maintain the infant's hydration status and electrolyte balance. Option A is incorrect because vital signs monitoring is important but insufficient for pre-operative care. Allowing parents to hold their infant can provide comfort and emotional support. Option C is incorrect as 100% oxygen via a non-rebreather mask is not typically indicated in this situation and may not address the immediate needs of the newborn. Option D is incorrect because feeding should be stopped well before surgery to prevent aspiration during induction of anesthesia. The infant should be kept NPO (nothing by mouth) for a sufficient time before surgery to reduce the risk of aspiration during the procedure. For nursing students preparing for the NCLEX, understanding the pre-operative care requirements for pediatric surgical patients is crucial. This scenario highlights the importance of infection prevention, hydration management, and NPO status before surgery in infants with tracheoesophageal fistula. It reinforces the need for evidence-based practice in pediatric nursing care.

Correct Answer: D

Rationale: The correct answer is D: Although your child will require surgery, there are different ways to manage the disease depending on how much of the bowel is involved. Rationale: - Correct Answer Explanation: Hirschsprung disease is a congenital condition where nerve cells are missing in the colon, leading to bowel obstruction. Surgery is the primary treatment, and the extent of surgery depends on how much of the bowel is affected. Different surgical approaches may be used to manage the condition effectively. - Incorrect Answers Explanation: A) Option A is incorrect because Hirschsprung disease requires surgical intervention and stool softeners alone will not resolve the condition. B) Option B is incorrect as colostomy is not the first-line treatment for Hirschsprung disease. Surgery aims to remove the affected segment of the bowel and reestablish normal bowel function. C) Option C is incorrect as daily bowel irrigations are not the mainstay of treatment for Hirschsprung disease. Surgery is the definitive treatment. Educational Context: Understanding the management of Hirschsprung disease is crucial for pediatric nurses as they care for children with this condition. By knowing the appropriate interventions, nurses can educate parents effectively and provide optimal care to the child. Highlighting the importance of surgical management and individualized treatment plans based on the extent of bowel involvement helps nurses deliver comprehensive care and support to families facing this diagnosis.