A nurse is caring for an infant waiting for surgical correction of intussusception. The child passes a diarrheal stool. Which action by the nurse is the most appropriate?
A.
Document the findings.
B.
Increase the IV fluid rate.
C.
Notify the physician.
D.
Weigh the child's diaper.
ANS: C
Intussusception is a condition in which a portion of the bowel invaginates or telescopes into another portion of bowel, creating a partial bowel obstruction. Spontaneous passage of stool may indicate resolution of the obstruction, so the nurse should contact the provider immediately. Documentation should always occur but is not the only action the nurse takes. Increasing the IV fluid rate based on passing a stool is not needed. Weighing the child's diaper is also not the priority.
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