Difficulty: Medium
Average Score: 71%
Simulated
An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?
Correct answer
C
Rationale
Measuring abdominal circumference assesses distension from potential obstruction (e.g., meconium ileus), the first action to evaluate severity and guide urgent care. IV supplies prepare for hydration or surgery, but assessment precedes intervention. Anorectal manometry diagnoses anal function, not relevant for bilious vomiting suggesting higher obstruction. Urinary output monitoring tracks hydration, secondary to gastrointestinal assessment.