Difficulty: Medium
Average Score: 75%
Simulated
Parents of an infant with an inguinal hernia bring their child to the emergency department reporting that the hernia has changed in color to dark purple and child has not had a bowel movement in 24 hours. The nurse obtains a Face, Legs, Activity, Cry, Consolability (FLACC) scale score of 8 on initial assessment. Which action should the nurse prioritize?
Correct answer
A
Rationale
A dark purple hernia, no bowel movement, and high FLACC score suggest strangulation, a surgical emergency. Reporting to the provider ensures urgent evaluation. Fluid intake, manual reduction, or IV access are secondary to addressing this critical condition.