A 4-year-old child returns home after day surgery for a tonsillectomy.

When the nurse calls the parent that evening to check on the child, the parent tells the nurse that the child said, “I'm too sick to feed myself.

Will you feed me?” Which response should the nurse provide to this parent?

Choice A rationale

Suggesting that the child is "manipulating" the parent is a non-therapeutic and judgmental response. It fails to recognize the psychological and emotional stress a child experiences after surgery. Post-surgical regression is a well-documented phenomenon. Labeling a child's behavior as manipulative can lead to a breakdown in the parent-child relationship and prevent the parent from providing the necessary emotional support and comfort the child needs during recovery. The nurse’s role is to educate, not judge.

Choice B rationale

While loneliness can be a factor, suggesting a friend visit immediately after a tonsillectomy is not the most appropriate advice. The child is in a recovery period and needs rest, comfort, and close observation. The presence of a visitor, while well-intentioned, could overstimulate the child and interfere with the necessary rest needed for healing. Post-tonsillectomy care prioritizes quiet recovery and minimizing activity. This advice is not aligned with the child’s physiological needs.

Choice C rationale

This response accurately explains the concept of regression, which is a common psychological defense mechanism in children who are ill or stressed. Regression involves reverting to behaviors characteristic of an earlier developmental stage to cope with overwhelming feelings or circumstances. Acknowledging this as a normal and temporary response validates the parent's concern and provides a scientific explanation, allowing them to respond with empathy and support. It reassures the parent that this behavior is expected and will likely resolve as the child recovers.

Choice D rationale

This response inappropriately suggests that the child's behavior stems from anger towards the parent. While children can be angry, framing this behavior solely as anger over the surgery is speculative and does not account for the more common and well-documented phenomenon of regression. This response can create guilt in the parent and distract from the actual cause of the behavior, which is a stress response to illness and surgery. It is not the most scientific or helpful explanation for the observed behavior.

Choice A rationale

A blood pressure of 130/70 mm Hg is within the normal range for a pregnant woman and does not indicate a hypertensive disorder. Normal blood pressure in pregnancy can fluctuate, but this reading is well below the threshold for preeclampsia or gestational hypertension, which is typically 140/90 mm Hg or higher.

Choice B rationale

Trace or 1+ proteinuria can be a normal finding in pregnancy and does not, in isolation, suggest a significant pathology. It is important to note that proteinuria, when part of a cluster of symptoms, is a diagnostic criterion for preeclampsia; however, a 1+ reading alone is often benign and may be related to factors like dehydration.

Choice C rationale

A temperature of 101.2° F (38.4° C) is a significant finding that indicates a fever, which can be a sign of infection. An infection in a pregnant woman, especially at term, can pose a risk to both the mother and the fetus and may necessitate immediate medical intervention, such as antibiotic therapy or a more extensive workup.

Choice D rationale

Mild pedal edema is a common and expected finding in the third trimester of pregnancy due to increased blood volume and pressure on the vena cava by the gravid uterus. This physiological change often leads to fluid retention in the lower extremities and is not typically a cause for concern unless it is severe, sudden, or accompanied by other signs of preeclampsia.