A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. Move the steps into the box in order of performance:
Inspection
Auscultation
Superficial palpation
Deep palpation
Correct Answer : A,B,C,D
The correct answer is a) Inspection, b) Auscultation, c) Superficial palpation, d) Deep palpation.
Choice A reason:
Inspection is the first step in an abdominal assessment. This involves visually examining the abdomen for any abnormalities such as distension, scars, lesions, or asymmetry. The nurse should note the shape, contour, and any visible movements or pulsations. This step is crucial as it provides the initial information about the patient’s condition and helps guide the subsequent steps of the assessment.
Choice B reason:
Auscultation follows inspection in the sequence of an abdominal assessment. The nurse uses a stethoscope to listen for bowel sounds in all four quadrants of the abdomen. This step is performed before palpation to avoid altering the natural bowel sounds. The presence, frequency, and character of bowel sounds can provide valuable information about the gastrointestinal function and help identify any abnormalities such as bowel obstruction or ileus.
Choice C reason:
Superficial palpation is the third step in the abdominal assessment sequence. The nurse gently palpates the abdomen to assess for tenderness, muscle tone, and any superficial masses. This step helps identify areas of discomfort or pain and provides information about the condition of the abdominal wall and underlying structures. It is important to perform this step gently to avoid causing discomfort or pain to the patient.
Choice D reason:
Deep palpation is the final step in the abdominal assessment sequence. The nurse applies more pressure to palpate deeper structures within the abdomen. This step helps assess for any deep-seated masses, organ enlargement, or areas of tenderness that were not detected during superficial palpation. Deep palpation should be performed carefully to avoid causing pain or discomfort to the patient.
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Correct Answer is D
Explanation
Choice A Reason:
Infants do not outgrow clubfoot on their own. Without treatment, the condition can lead to significant disability and difficulty walking. Early intervention is crucial to correct the deformity and ensure proper foot function.
Choice B Reason:
Surgical intervention is not the first line of treatment for mild cases of clubfoot. Surgery is typically reserved for severe cases or when nonsurgical methods, such as casting, have failed. The goal is to correct the foot’s position using less invasive methods whenever possible.
Choice C Reason:
Traction with foot manipulation is not a standard treatment for clubfoot. The primary nonsurgical treatment involves the Ponseti method, which includes gentle manipulation and serial casting to gradually correct the foot’s position.
Choice D Reason:
Frequent serial casting, known as the Ponseti method, is the first line of treatment for clubfoot. This method involves weekly manipulation and casting of the foot to gradually move it into the correct position. It is highly effective and is the preferred initial treatment for most cases of clubfoot.
Correct Answer is D
Explanation
Choice A reason:
Peanuts are not recommended for infants, especially those under one year of age, due to the risk of choking and potential allergies. Additionally, peanuts are not a significant source of iron and would not be effective in preventing iron deficiency anemia in infants. Therefore, this choice is not appropriate for preventing iron deficiency anemia in a 6-month-old infant.
Choice B reason:
Iron (ferrous sulfate) tablets are not typically recommended for infants unless prescribed by a healthcare provider. Infants who are exclusively breastfed or partially breastfed should receive iron supplementation starting at 4-6 months of age, but this is usually in the form of liquid drops rather than tablets. It is important to follow the guidance of a healthcare provider when administering iron supplements to infants.
Choice C reason:
Sautéed liver is a rich source of iron, but it is not suitable for a 6-month-old infant. Introducing solid foods to infants should be done gradually, starting with iron-fortified cereals and pureed fruits and vegetables. Liver can be introduced later as part of a balanced diet, but it is not the first choice for preventing iron deficiency anemia in a young infant.
Choice D reason:
Iron-fortified baby cereal is the recommended choice for preventing iron deficiency anemia in a 6-month-old infant who is still breastfeeding. These cereals are specifically designed to provide the necessary iron that infants need as they transition to solid foods. Starting with iron-fortified cereals helps ensure that the infant receives adequate iron to support healthy growth and development.
