The nurse is caring for a post-operative pyloromyotomy infant.
Which of the following interventions should be performed first?
Begin feeding with small amounts of electrolyte solution.
Encourage parental bonding and cuddling.
Document the surgical site appearance.
Identify signs of pain using an appropriate pain scale.
The Correct Answer is D
Choice A rationale
Initiating feeding too soon after pyloromyotomy, a surgical repair of the pyloric sphincter, can lead to vomiting and aspiration in the immediate postoperative period. The gastrointestinal system needs time to recover from anesthesia and the surgical manipulation to the pylorus, which controls the passage of food from the stomach to the small intestine. Introducing fluids prematurely can overwhelm the healing surgical site.
Choice B rationale
Encouraging parental bonding and cuddling is crucial for the psychosocial well-being of the infant and parents. However, in the immediate postoperative phase, physiological stability takes precedence. While emotional support is important, addressing potential complications and assessing the infant's physical status are the priority actions.
Choice C rationale
Documenting the surgical site appearance is an important nursing responsibility to monitor for signs of infection, bleeding, or dehiscence. However, assessing the infant's immediate postoperative condition, particularly pain, which can indicate complications or discomfort, is a more immediate concern. Pain management directly impacts the infant's physiological stability.
Choice D rationale
Identifying signs of pain using an appropriate pain scale is the priority intervention in a post-operative infant. Pain can lead to physiological instability, such as increased heart rate, blood pressure, and respiratory distress. Early identification and management of pain ensure the infant's comfort and facilitate recovery. Utilizing a validated pain scale for infants allows for objective assessment of pain levels and guides appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Inserting a nasogastric tube for decompression of the abdomen is a standard intervention for suspected Hirschsprung's disease, which is characterized by a lack of ganglion cells in a segment of the colon, leading to impaired motility and potential bowel obstruction. Decompression helps relieve abdominal distension and pressure.
Choice B rationale
NPO status and initiating IV fluids are appropriate initial management for a child with suspected Hirschsprung's disease to rest the bowel and maintain hydration and electrolyte balance while further diagnostic tests are performed.
Choice C rationale
Monitoring abdominal girth every 4 hours is essential to assess for increasing abdominal distension, which can indicate worsening obstruction in Hirschsprung's disease. An increasing girth would warrant further investigation and intervention.
Choice D rationale
Administering a large-volume liquid enema is contraindicated in suspected Hirschsprung's disease. Due to the aganglionic segment's impaired motility, the enema fluid may not be expelled and could lead to fluid overload or bowel perforation. Diagnostic enemas using contrast are performed under controlled conditions.
Correct Answer is D
Explanation
Choice D rationale
Same-sex peer group activity becomes increasingly important during the school-aged years (approximately 6 to 12 years). Children in this stage develop a strong sense of belonging and identity within these groups, engaging in cooperative play, sharing interests, and establishing social norms.
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