Question

The nurse provides care for an infant who passes red-jelly like stool. The parents report that the child cries with bowel movements and abdominal guarding is noted by the nurse. Which is the priority action by the nurse based on the current data?

A. Assess the infant's ability to swallow and keep down fluid.
B. Give one unit of packed red blood cells (RBCs), as prescribed.
C. Prepare to administer an air enema, as prescribed.
D. Send a stool sample to the laboratory for hemoccult testing.

Answer 1

The nurse's priority should be to prepare to administer an air enema, as it is a critical intervention that can diagnose and treat intussusception, a suspected condition in infants with red-jelly like stools and abdominal guarding.

Step-by-step explanation:

Prioritizing Nursing Actions for Infants

An infant presenting with red-jelly like stools and symptoms of discomfort during bowel movements, along with findings of abdominal guarding, may be experiencing intussusception a condition where part of the intestine telescopes into itself. This is a medical emergency requiring prompt attention, often managed with an air enema. This procedure can both diagnose and treat the condition, potentially avoiding surgery. The nurse's priority action would be to prepare to administer an air enema, as per physician's orders, to try to correct the intussusception.

While sending a stool sample for a hemoccult test can confirm the presence of blood in the stool and possibly identify causative infectious agents, it is not the immediate priority in a case where intussusception is suspected. Similarly, although assessing the infant's ability to swallow is important, it does not address the acute concern. Giving packed RBCs may be necessary if there's significant blood loss, but it's a subsequent step, dependent on the infant's overall condition and hemodynamic stability.