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 A
Explanation
Choice A reason:
Congenital adrenal hyperplasia (CAH) is a group of genetic disorders affecting the adrenal glands, which are responsible for producing vital hormones such as cortisol, aldosterone, and androgens. In CAH, there is a deficiency of the enzyme 21-hydroxylase, which is crucial for the synthesis of cortisol and aldosterone. As a result, the adrenal glands overproduce androgens, leading to symptoms such as ambiguous genitalia in newborns, early puberty, and rapid growth. Androgens are male sex hormones, including testosterone, which play a significant role in the development of male characteristics.
Choice B reason:
Vitamin K is a fat-soluble vitamin essential for blood clotting and bone health. It is not related to the overproduction of hormones in congenital adrenal hyperplasia. Vitamin K deficiency can lead to bleeding disorders, but it does not cause the symptoms associated with CAH, such as ambiguous genitalia or early puberty. Therefore, this choice is incorrect.
Choice C reason:
Gonadotropins are hormones produced by the pituitary gland that stimulate the gonads (ovaries and testes) to produce sex hormones and gametes (eggs and sperm). While gonadotropins play a role in sexual development and reproduction, they are not overproduced in congenital adrenal hyperplasia. The primary issue in CAH is the overproduction of androgens due to enzyme deficiencies in the adrenal glands. Therefore, this choice is incorrect.
Choice D reason:
Vitamin D is a fat-soluble vitamin essential for calcium absorption and bone health. It is not related to the overproduction of hormones in congenital adrenal hyperplasia. Vitamin D deficiency can lead to bone disorders such as rickets in children and osteomalacia in adults, but it does not cause the symptoms associated with CAH. Therefore, this choice is incorrect.
Correct Answer is D
Explanation
Choice A reason:
Feeding an infant with gastroesophageal reflux formula instead of breast milk is not necessary. Breast milk is often easier for infants to digest and can be beneficial for reducing reflux symptoms. According to the American Academy of Pediatrics, breastfeeding should be continued if possible, as it has numerous health benefits for both the infant and the mother. If formula feeding is necessary, specialized formulas designed for infants with reflux can be used, but this does not mean breast milk should be avoided.
Choice B reason:
Thinning the baby’s formula with water is not recommended. This practice can dilute the essential nutrients in the formula, leading to inadequate nutrition for the infant. Instead, thickening agents such as rice cereal can be added to the formula to help reduce reflux symptoms. This approach helps the formula stay down in the stomach and reduces the likelihood of regurgitation.
Choice C reason:
Positioning the baby side-lying during sleep is not recommended for infants with gastroesophageal reflux. The American Academy of Pediatrics advises that infants should be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Side-lying or prone positions are not safe for sleep and do not effectively reduce reflux symptoms.
Choice D reason:
Keeping the baby in an upright position after feedings is the correct approach for managing gastroesophageal reflux. This position helps prevent the stomach contents from flowing back into the esophagus, reducing the likelihood of reflux. It is recommended to hold the baby upright for at least 20-30 minutes after feeding to allow gravity to assist in keeping the stomach contents down.