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:
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.
Correct Answer is D
Explanation
Choice A reason:
Reducing blood pressure is not a primary management goal for nephrotic syndrome in children. While hypertension can be a complication of nephrotic syndrome, the main focus of treatment is on managing proteinuria, edema, and preventing complications. Blood pressure management may be necessary, but it is not the primary goal.
Choice B reason:
Increasing the excretion of urinary protein is not a desired goal in the management of nephrotic syndrome. In fact, one of the main objectives is to reduce proteinuria (excessive protein in the urine) because it leads to hypoalbuminemia (low levels of albumin in the blood) and edema. Therefore, increasing urinary protein excretion would worsen the condition.
Choice C reason:
Increasing the ability of tissues to retain fluid is not a management goal for nephrotic syndrome. The condition is characterized by edema due to fluid retention, and the goal is to reduce this edema by managing proteinuria and using diuretics if necessary. Therefore, increasing fluid retention would be counterproductive.
Choice D reason:
Reducing the excretion of urinary protein is a primary management goal for nephrotic syndrome1. Proteinuria is a hallmark of the condition, and reducing it helps to alleviate hypoalbuminemia and edema. Treatment often includes corticosteroids to reduce inflammation and protein leakage, as well as other medications to manage symptoms and prevent complications.