# A 9-month-old infant is admitted to the pediatric unit with suspected intussusception. The infant has been experiencing intermittent abdominal pain, vomiting, and has passed one stool containing blood and mucus. What is the priority nursing intervention for this infant?

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> subject: Child Health

## 문제

A 9-month-old infant is admitted to the pediatric unit with suspected intussusception. The infant has been experiencing intermittent abdominal pain, vomiting, and has passed one stool containing blood and mucus. What is the priority nursing intervention for this infant?

## 보기

1. Administer prescribed analgesics to manage the infant's intermittent pain
2. Prepare the infant for immediate diagnostic imaging and possible therapeutic intervention **✔ 정답**
3. Encourage oral fluid intake to prevent dehydration in the infant
4. Apply warm compresses to the abdomen to reduce the infant's discomfort

**정답: 2**

## 해설

Intussusception is a pediatric emergency requiring immediate diagnosis and intervention to prevent bowel necrosis. Priority nursing intervention is preparing for diagnostic imaging and therapeutic procedures, as non-surgical reduction (e.g., barium enema) is time-sensitive. Other options address supportive care but delay critical treatment.

## 심화 해설

Understanding Intussusception

Intussusception is a serious condition where a proximal segment of the intestine telescopes into a distal segment, leading to bowel obstruction, venous compression, edema, and eventually arterial insufficiency. In a 9-month-old infant presenting with the classic triad of intermittent abdominal pain, vomiting, and the passage of "currant jelly" stool (blood and mucus), the condition is a medical emergency. The primary concern is that prolonged intussusception leads to bowel ischemia, necrosis, and perforation.

Why Option 2 is the Priority

The priority nursing intervention is to prepare the infant for immediate diagnostic imaging and possible therapeutic intervention. The rationale is grounded in the time-sensitive nature of the condition. A study on the impact of a delay between diagnostic ultrasound and fluoroscopic reduction for ileocolic intussusception highlights that this is considered a radiologic urgency requiring 24-hour availability of radiologists and technologists . While the study assessed outcomes related to a 6–12 hour delay, the underlying principle is that timely reduction is critical to maximize the chance of a successful non-surgical reduction and to minimize the risk of bowel ischemia. The nurse's role is to facilitate this process urgently by ensuring NPO (nothing by mouth) status, establishing IV access, and coordinating with the radiology and surgical teams.

Analysis of Incorrect Options

- Option 1 (Administer prescribed analgesics): While pain management is an important nursing consideration, it is not the priority. Administering an analgesic before a definitive diagnosis or intervention could mask a critical change in the infant's pain pattern, such as a sudden cessation of pain that could indicate perforation. The priority is to address the underlying cause of the pain, which is the obstruction.

- Option 3 (Encourage oral fluid intake): This intervention is contraindicated. The infant has a bowel obstruction and is vomiting. Oral intake would worsen vomiting, increase the risk of aspiration, and is not an effective way to manage dehydration in this scenario. The infant should be kept NPO in preparation for a procedure or potential surgery.

- Option 4 (Apply warm compresses to the abdomen): This provides minimal comfort and does nothing to address the life-threatening bowel obstruction. It delays definitive care and could potentially mask symptoms without treating the underlying pathology.

The urgency of the situation is paramount. The clinical presentation of a "currant jelly" stool is a late sign indicating bowel ischemia and mucosal sloughing. Immediate reduction, typically via air or contrast enema under fluoroscopic guidance, is the definitive treatment to salvage the bowel . The nurse's priority is to prepare the patient for this time-critical intervention.

## 임상 시나리오

Intussusception: Urgent Nursing PriorityImmediate action to prevent bowel necrosis
For a 9-month-old with the classic triad of pain, vomiting, and currant jelly stool, intussusception is a radiologic urgency. The priority is preparing for immediate diagnostic imaging (ultrasound) and possible therapeutic reduction (air or contrast enema).

The nurse must establish NPO status immediately, secure IV access, and coordinate with radiology and surgery. A delay of even 6–12 hours can decrease the success of non-surgical reduction and increase the risk of bowel ischemia and perforation.

CautionDo not administer oral fluids or analgesics before the diagnosis is confirmed and reduction is attempted. Pain management and comfort measures are secondary to definitive, time-sensitive intervention.

## 핵심 개념

- **Intussusception** — A condition where a proximal segment of intestine telescopes into a distal segment, causing bowel obstruction and ischemia.
- **Currant jelly stool** — A classic sign of intussusception consisting of stool mixed with blood and mucus, indicating intestinal ischemia.
- **NPO** — Nothing by mouth; a necessary status before diagnostic or therapeutic procedures to reduce aspiration risk.
- **Bowel ischemia** — Reduced blood flow to the intestines, leading to tissue damage and potentially necrosis if not promptly resolved.
- **Fluoroscopic reduction** — A non-surgical therapeutic procedure using contrast enema under imaging to reduce the intussusception.

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