Exhibits

The nurse is reviewing the assessment data.

Which are the 3 most likely reasons that the infant is crying?

A. Hunger – The infant is NPO postoperatively but is accustomed to regular feedings. Hunger-related distress is common in infants after surgery, especially when oral intake is restricted. Since the infant has a history of GERD and fundoplication surgery, feedings are likely delayed to prevent complications, contributing to crying.
B. Opioid withdrawal – There is no indication that the infant has been on chronic opioid therapy before surgery. Opioid withdrawal symptoms typically occur in infants exposed to opioids for prolonged periods (e.g., neonatal abstinence syndrome), which is not relevant in this case.
C. Hemorrhage – The surgical dressing is clean and dry, meaning there are no visible signs of bleeding at the incision site. If significant internal bleeding were occurring, the infant would likely show signs of pallor, tachycardia, and hypotension, which are not present.
D. Separation anxiety – Separation anxiety typically develops around 6–9 months of age, when infants become more aware of their caregivers' presence. At 4 months, infants can recognize caregivers but do not yet exhibit true separation distress, making this an unlikely reason for crying.
E. Pain – Postoperative pain is a common cause of crying in infants after surgery. Signs of pain in nonverbal infants include crying, facial grimacing, irritability, and body tension. Since the infant has just undergone fundoplication surgery, pain is a likely contributing factor.
F. Hypovolemia – The infant is receiving IV fluids (Dextrose 5% with sodium chloride 0.45%), but fluid deficits can still occur postoperatively due to preoperative fasting, surgical fluid losses, or inadequate replacement. Hypovolemia can cause discomfort, irritability, tachycardia, and crying.
G. Hypoxia – The infant is described as pink and well-perfused with clear breath sounds, which rules out respiratory distress as a likely cause of crying. If hypoxia were present, signs such as cyanosis, increased work of breathing, or abnormal breath sounds would be expected.

A. Establish the frequency of headaches. While assessing headache history is important, an excruciating headache in a pregnant client with elevated blood pressure is a concerning sign of possible preeclampsia. Immediate evaluation for organ involvement, such as proteinuria, is more critical than determining headache patterns.
B. Ask about a history of delivering large babies. A history of macrosomia is more relevant for assessing gestational diabetes rather than hypertensive disorders. In this case, the priority is identifying potential complications of preeclampsia, which requires urine protein testing.
C. Examine the client for pedal edema. Although edema can be a sign of preeclampsia, it is also common in normal pregnancy. Generalized edema, particularly in the face and hands, may be more concerning, but the presence or absence of edema does not confirm or rule out preeclampsia.
D. Collect a urine sample to screen for protein. Proteinuria is a key diagnostic criterion for preeclampsia, along with hypertension and systemic symptoms such as severe headache. A urine dipstick or 24-hour urine collection helps determine if the client has preeclampsia, which requires urgent management to prevent complications like eclampsia or placental abruption.