A nurse is caring for an infant following surgical repair of omphalocele. What is the nurse's priority?
Administer pain medication as ordered
Assess the surgical site for signs of infection
Educate the parents about proper wound care
Provide age-appropriate toys for play
The Correct Answer is B
A. Administering pain medication is important, but assessing the surgical site for signs of infection takes priority to prevent complications.
B. Assessing the surgical site for signs of infection is crucial in preventing complications and ensuring proper healing post-surgery.
C. Educating the parents about proper wound care is essential but may not be the priority compared to assessing for signs of infection.
D. Providing age-appropriate toys for play is important for the infant's comfort and development but is not the priority compared to assessing for signs of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Although monitoring is important, the low urine output and weight of the child warrant further intervention.
B. With such low urine output, especially considering the child's weight, notifying the healthcare provider is essential for further evaluation and management. At 33 lbs, the child's expected urine output is closer to 1 ml/kg/hr (around 33 ml/hr).
C. Oral rehydration fluids may be indicated for dehydration but should be guided by healthcare provider orders.
D. A bladder scan may not provide relevant information in this case of oliguria; notification of the provider is more appropriate.
Correct Answer is D
Explanation
A. Placing the infant on the left side may increase the risk of aspiration if reflux occurs.
B. Placing the infant on the right side may not effectively prevent reflux and could increase the risk of aspiration.
C. Placing the infant in a prone position increases the risk of aspiration and is not recommended, especially after feedings.
D. Placing the infant in an infant seat can help prevent reflux by keeping the baby upright and allowing gravity to assist in digestion.
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