Exhibits

A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. Extend the client's legs above heart level: Elevating the legs may improve venous return but does not reduce tension on the abdominal incision or help prevent further dehiscence. It does not address the immediate concern of protecting the surgical site.

B. Place the client in a low-fowler's position: Positioning the client in a low-Fowler’s position (head of bed at 15–30 degrees) helps reduce intra-abdominal pressure on the incision and prevents further separation of the wound edges. This positioning supports comfort and minimizes strain while preparing for dressing application or further intervention.

C. Instruct the client to perform the Valsalva maneuver: Asking the client to strain or hold their breath increases intra-abdominal pressure, which can worsen dehiscence and increase the risk of evisceration. This action is unsafe and should be avoided.

D. Apply a dry gauze dressing to the incision: Applying a dry dressing alone does not protect the exposed tissue and may increase the risk of infection if evisceration occurs. The initial priority is to reduce tension on the wound by positioning before implementing sterile protective measures, such as a saline-moistened sterile dressing if necessary.

A. The newborn's neck is short and surrounded by skin folds: A short neck with skin folds can be a normal variant in some newborns, especially those with subcutaneous fat. While it may warrant observation for potential anomalies, it is not an immediate concern at 24 hours of age.

B. The newborn's glucose level is 50 mg/dL: A glucose level of 50 mg/dL is within the normal range for a full-term newborn. Routine monitoring is sufficient, and this finding does not require urgent reporting.

C. The newborn's sclerae have a yellowish tint: Jaundice appearing within the first 24 hours of life can indicate pathological jaundice, which may result from hemolysis, infection, or metabolic disorders. Early-onset jaundice requires prompt evaluation and intervention to prevent complications such as kernicterus.

D. The newborn has experienced a weight loss of 3% since birth: A weight loss of up to 5–7% in the first few days after birth is considered normal due to fluid shifts. A 3% loss is expected and does not necessitate immediate reporting.