A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2. b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3. c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4. d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5. e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.

Choice A reason: Apply Bilateral Wrist Restraints

Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.

Choice B reason: Administer Opioids for Pain

Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.

Choice C reason: Implement a Soft Diet

Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.

Choice D reason: Offer Fluids Through a Straw

Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.