The nurse will soon receive a 4-month-old who has been diagnosed with intussusception. The infant is very lethargic with the following vital signs: T 101.8°F (38.7°C), HR 181, BP 68/38; the reporting nurse states the infant's abdomen is very rigid. Which is the most appropriate action for the receiving nurse?

Correct Answer: D

Rationale: The most appropriate action for the receiving nurse in this scenario is to prepare to get the infant ready for immediate surgical correction (Option D). Intussusception is a medical emergency where a part of the intestine folds into itself, leading to obstruction and compromised blood flow. The infant's presentation with lethargy, high fever, tachycardia, hypotension, and a rigid abdomen indicates a severe case requiring urgent surgical intervention to prevent complications like bowel perforation, sepsis, and even death. Option A (CT scan) is not the immediate priority as the infant's condition is critical and waiting for imaging could delay life-saving treatment. Option B (reducing enema) may be contraindicated if the bowel is perforated or compromised, as in this case. Starting a second IV line for fluids and antibiotics (Option C) is important but secondary to addressing the immediate surgical need to correct the intussusception. In an educational context, understanding the urgency of surgical intervention in cases of intussusception is crucial for nurses caring for pediatric patients. Recognizing the signs and symptoms of this condition and knowing the appropriate interventions can help prevent complications and ensure positive outcomes for the child. It highlights the importance of swift clinical judgment and prioritization in emergency situations.

Correct Answer: B

Rationale: Rationale: The correct answer is B) Clear liquids such as broth and Jell-O. Children with hepatitis often experience reduced appetite, nausea, and digestive issues. Offering clear liquids like broth and Jell-O is gentle on the digestive system, easy to digest, and helps maintain hydration, which is crucial for liver health and overall recovery. Option A) A tuna sandwich on whole wheat bread and a cup of skim milk is not the best choice for a child with hepatitis because fatty and heavy foods can exacerbate digestive symptoms and strain the liver. Option C) A hamburger, French fries, and a diet soda are high in fat, salt, and processed ingredients, which can be difficult for a child with hepatitis to digest and may worsen symptoms. Option D) A peanut butter sandwich and a milkshake are high in fat and may be too heavy for a child with hepatitis, potentially leading to discomfort and further digestive issues. Educational Context: Understanding the dietary needs of children with hepatitis is crucial for nurses and healthcare professionals, especially when preparing meals for pediatric patients. Providing appropriate foods that are easy to digest, gentle on the liver, and support hydration can aid in the child's recovery process and overall well-being. Educating caregivers about the importance of a hepatic-friendly diet for children with hepatitis is essential in promoting optimal health outcomes.

Correct Answer: A

Rationale: In the early stages of acute hepatitis in a child, the nurse should expect manifestations such as nausea, vomiting, and generalized malaise, which are consistent with Option A. This is because acute hepatitis typically presents with non-specific symptoms such as gastrointestinal disturbances and malaise before progressing to more specific signs like jaundice. Option B is incorrect because pain in the left upper quadrant is more commonly associated with conditions like pancreatitis or splenomegaly rather than acute hepatitis in children. Option C is incorrect as yellowing of the skin and sclera (jaundice) usually appears later in the course of hepatitis, not in the early stages as described in the question. Option D is also incorrect as yellowing of the skin and sclera alone without other generalized complaints is less likely to be seen in the early stages of acute hepatitis in children. Educationally, understanding the progression of symptoms in pediatric hepatitis is crucial for nurses to provide timely and appropriate care. Recognizing the early signs allows for prompt intervention and management, potentially preventing further complications. It is important for nurses to be able to differentiate between the various manifestations of liver disorders in children to ensure accurate assessment and care planning.

Correct Answer: A

Rationale: The correct answer is A) congenital microvillus disease. In this condition, the neonate presents with watery and voluminous stool, which can be mistaken for urine due to its appearance. Congenital microvillus disease is a rare genetic disorder affecting the small intestine's ability to absorb nutrients properly. This leads to severe diarrhea and malabsorption of nutrients, resulting in the characteristic stool presentation described in the question. Option B) congenital enterokinase deficiency is incorrect because this condition primarily affects protein digestion by impairing the activation of trypsinogen to trypsin, leading to protein malabsorption, not watery stool. Option C) congenital trypsinogen deficiency is incorrect as it leads to impaired protein digestion, not the watery stool described in the question. Option D) congenital bile acid malabsorption is incorrect as it primarily affects fat absorption, leading to fatty stools, not watery and voluminous stool as seen in congenital microvillus disease. Understanding pediatric gastrointestinal disorders is crucial for nurses and healthcare professionals caring for neonates and children. Recognizing the signs and symptoms of conditions like congenital microvillus disease is essential for timely diagnosis and intervention to prevent complications like malnutrition and dehydration. Knowledge of these conditions is vital for providing quality care and improving patient outcomes in pediatric settings.

Correct Answer: A

Rationale: The correct answer is A) food protein allergy. In infants and young toddlers, chronic diarrhea following infectious enteritis can be related to food protein allergy. This is because the inflammation and damage caused by the initial infection can lead to the development of an allergy to certain food proteins, which in turn can trigger chronic diarrhea. Option B) bacterial overgrowth is not typically associated with chronic diarrhea following infectious enteritis in infants and very young toddlers. Bacterial overgrowth is more commonly seen in conditions like small intestinal bacterial overgrowth (SIBO) or malabsorption syndromes. Option C) giardiasis is a specific parasitic infection caused by Giardia lamblia and would present with its own set of symptoms, including diarrhea, but it is not the most likely cause of chronic diarrhea following infectious enteritis. Option D) eosinophilic gastroenteropathy is a condition characterized by high levels of eosinophils in the gastrointestinal tract, leading to inflammation and various gastrointestinal symptoms. While this condition can cause chronic diarrhea, it is not typically the primary concern following infectious enteritis in infants and very young toddlers. Understanding the potential causes of chronic diarrhea following infectious enteritis in young children is crucial for healthcare providers, especially those preparing for the NCLEX exam. Recognizing the role of food protein allergy in this context can help in appropriate management and treatment of the condition, ensuring better outcomes for pediatric patients.