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:
In premature infants, it is common for the testes to not be palpable in the scrotum at birth. This condition, known as cryptorchidism, affects about 30% of preterm infants1. The testes usually descend into the scrotum by the time the infant reaches term or within the first few months of life. Therefore, the nurse should document this as an expected finding and continue to monitor the infant’s development.
Choice B reason:
Inserting a urinary catheter to collect a urine specimen is not necessary in this situation. The absence of palpable testes in a premature infant is a common finding and does not indicate a need for immediate urinary evaluation. Urinary catheterization should be reserved for specific medical indications, such as suspected urinary tract infection or urinary retention.
Choice C reason:
Initiating a social work consult is not relevant to the clinical finding of undescended testes in a premature infant. Social work consultations are typically initiated for psychosocial issues, family support, or discharge planning. The absence of palpable testes is a medical finding that should be documented and monitored by the healthcare team.
Choice D reason:
Calling the provider for this unexpected finding is not necessary because the absence of palpable testes in a premature infant is an expected finding. The nurse should document the finding and continue to monitor the infant’s development. If the testes do not descend by the time the infant reaches term or within the first few months of life, further evaluation and management may be needed.
Correct Answer is C
Explanation
Choice A: Apply antibiotic ointment to pin sites daily
Applying antibiotic ointment to pin sites daily is not relevant in the context of Buck extension traction. Buck’s traction is a type of skin traction, which does not involve pins or pin sites. Pin site care is typically associated with skeletal traction, where pins are inserted directly into the bone.
Choice B: Remove the traction boot during baths
Removing the traction boot during baths is not recommended. The traction boot should remain in place to maintain the alignment and immobilization of the affected limb. Removing the boot can disrupt the traction and potentially worsen the condition.
Choice C: Assess neurovascular status every 2 hours
Assessing neurovascular status every 2 hours is crucial for a child in Buck extension traction. This involves checking the circulation, sensation, and movement of the affected limb to ensure there are no complications such as nerve damage or impaired blood flow. Regular neurovascular assessments help in early detection and prevention of complications.
Choice D: Reduce fluid intake
Reducing fluid intake is not a standard care practice for a child in Buck extension traction. Adequate hydration is important for overall health and recovery. There is no indication that fluid intake should be restricted in this scenario.