A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?
Plan for nurses to provide the feedings.
Report this finding to the health care provider.
Assure the mother that this is a normal finding.
Tell the mother it is all right to feel anxious.
The Correct Answer is B
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
Correct Answer is A
Explanation
Choice A rationale:
Expiratory wheezing is characteristic of asthma exacerbation. It indicates airway constriction and narrowing, leading to difficulty in exhaling and resulting in a high-pitched sound during expiration.
Choice B rationale:
Inspiratory crackle is not typically associated with asthma. Crackles are often heard in conditions involving fluid-filled airways, such as pneumonia.
Choice C rationale:
Expiratory grunting is not a common finding in asthma. Grunting sounds may be present in infants with respiratory distress, indicating the difficulty they experience while exhaling.
Choice D rationale:
Inspiratory stridor is not a usual manifestation of asthma. Stridor is more commonly related to upper airway obstruction, often seen in croup or epiglottitis.
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