The nurse is caring for a two-year-old client who presented to the ER with vomiting, currant jelly-like stools, and abdominal pain that causes the child to draw the knees up to the abdomen in a fetal position. Which interventions does the nurse anticipate for this client?
monitoring for fever and changes in blood pressure
Numbers 1, 3, 5, and 6 are correct.
Rationale: This client is exhibiting signs of intussusception. The nurse should monitor for and report respiratory distress immediately. Respiratory distress can be caused by pressing the knees up to the abdomen. Passage of a normal, brown stool indicates reduction of the intussusception. An NG tube is placed to decompress the stomach. Fever and changes in blood pressure can indicate perforation and shock. The client should be kept NPO until the intussusception is resolved. A barium enema is contraindicated for any client at risk of bowel perforation.
