A nurse in a clinic is caring for a client who is pregnant and asks how she should help her 4-year-old son prepare for the new baby. Which of the following statements should the nurse make?

A. Irrigate the wound using a 10-mL syringe. A 10-mL syringe does not provide adequate pressure for effective irrigation. Typically, a 30- to 60-mL syringe with an 18-gauge catheter is used to deliver appropriate pressure (between 4–15 psi) to clean wounds effectively.
B. Irrigate the wound with a low-pressure flow of solution. This is correct. A low-pressure irrigation system helps gently remove debris and bacteria without damaging healthy tissue. It also minimizes the risk of forcing contaminants deeper into the wound bed.
C. Cleanse the insertion site of the drain using a circular motion toward the center. The site should be cleansed from the center outward, not toward the center, to prevent dragging contaminants into the insertion site and reduce infection risk.
D. Cleanse the wound starting at the bottom and moving upward. Wound cleaning should occur from the least contaminated (top) to the most contaminated (bottom) area to avoid transferring microorganisms from dirtier areas to cleaner areas, thereby minimizing the risk of infection.

• Postoperative ileus: Ileus is a common complication after abdominal surgery due to anesthesia, opioid use, and limited mobility. It presents as delayed return of bowel function, marked by absent bowel sounds and abdominal discomfort. In this case, the child has absent bowel sounds and increasing tenderness, supporting this risk.
• Atelectasis: Atelectasis generally presents with diminished breath sounds and hypoxia, not clear breath sounds. Although the child has shallow respirations and is refusing the incentive spirometer, there are no respiratory findings such as decreased oxygen saturation or adventitious breath sounds that support this condition currently.
• Peritonitis: Peritonitis would present with systemic symptoms like fever, severe abdominal pain, rebound tenderness, or signs of sepsis. The child has mild abdominal tenderness and stable vital signs, which do not indicate peritoneal inflammation at this time.
• Urinary retention: This would be characterized by lack of urination, bladder distension, or discomfort—none of which are noted in the scenario. The child’s urinary output and bladder status are not identified as concerns, making this diagnosis unlikely.
• Absent bowel sounds: This is a key clinical sign of ileus. After surgery, bowel activity should return gradually. Continued absence of sounds, especially along with abdominal tenderness, strongly indicates impaired gastrointestinal motility.
• Shallow respirations: While shallow breathing is often a contributing factor to respiratory complications, in the context of abdominal surgery, it also limits diaphragmatic movement, which can further suppress bowel activity and contribute to postoperative ileus.
• Clear breath sounds: This is a normal respiratory finding and does not support the presence of atelectasis or other pulmonary complications. It suggests that lung fields are adequately ventilated despite shallow breathing.
• Intact abdominal dressing: This is an expected postoperative finding and does not support a diagnosis of infection, wound complication, or ileus. It indicates proper surgical wound healing.