A 9-month-old infant with a diagnosis of gastroesophageal reflux (GER) is being discharged from the hospital.
The nurse is educating the parents about signs of possible complications related to GER.
Which of the following signs should the parents report immediately to the pediatrician?

Choice A rationale

Initiating feeding too soon after pyloromyotomy, a surgical repair of the pyloric sphincter, can lead to vomiting and aspiration in the immediate postoperative period. The gastrointestinal system needs time to recover from anesthesia and the surgical manipulation to the pylorus, which controls the passage of food from the stomach to the small intestine. Introducing fluids prematurely can overwhelm the healing surgical site.

Choice B rationale

Encouraging parental bonding and cuddling is crucial for the psychosocial well-being of the infant and parents. However, in the immediate postoperative phase, physiological stability takes precedence. While emotional support is important, addressing potential complications and assessing the infant's physical status are the priority actions.

Choice C rationale

Documenting the surgical site appearance is an important nursing responsibility to monitor for signs of infection, bleeding, or dehiscence. However, assessing the infant's immediate postoperative condition, particularly pain, which can indicate complications or discomfort, is a more immediate concern. Pain management directly impacts the infant's physiological stability.

Choice D rationale

Identifying signs of pain using an appropriate pain scale is the priority intervention in a post-operative infant. Pain can lead to physiological instability, such as increased heart rate, blood pressure, and respiratory distress. Early identification and management of pain ensure the infant's comfort and facilitate recovery. Utilizing a validated pain scale for infants allows for objective assessment of pain levels and guides appropriate interventions.

Choice A rationale

Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.

Choice B rationale

No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.

Choice C rationale

Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.

Choice D rationale

Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.