Difficulty: Medium
Average Score: 76%
Simulated
The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?
Correct answer
D
Rationale
Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.