The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is most important?

Question

Quizplus · Accepted Answer

Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery. (Option B) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. (Option C) Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception. (Option D) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced. Educational objective: Reduction of intussusception is often performed with a saline or air enema. The HCP should be notified if there is passage of a normal stool as this indicates reduction of the intussusception. All plans for surgery should be stopped and the plan of care should be modified.

The Nurse Is Caring for a 2-Year-Old Who Is Receiving