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 B
Explanation
Choice A rationale
Pain is a common symptom in superficial and partial-thickness burns where nerve endings are still intact. While pain indicates tissue damage, the absence of pain in a burn area can signify deeper and more severe injury where nerve endings have been destroyed.
Choice B rationale
No pain with pale, leathery skin is a characteristic finding of a full-thickness (third-degree) burn. The destruction of nerve endings eliminates pain sensation, and the skin appears dry, leathery, and may be white, charred, or translucent due to damage to all skin layers and underlying tissue.
Choice C rationale
Mild erythema, or redness of the skin, is characteristic of a superficial (first-degree) burn, such as a sunburn. These burns involve only the epidermis and are typically painful and without blisters.
Choice D rationale
Blister formation is a hallmark of partial-thickness (second-degree) burns, which involve the epidermis and part of the dermis. These burns are typically painful and moist.
Correct Answer is C
Explanation
Choice A rationale
Limiting fluid intake is generally not indicated for atopic dermatitis unless there is a specific comorbid condition warranting fluid restriction. Maintaining adequate hydration is usually encouraged for overall skin health.
Choice B rationale
Promoting peeling of dead skin is not a primary goal in managing atopic dermatitis. The focus is on reducing inflammation, relieving itching, and maintaining skin hydration and barrier function, not necessarily on exfoliation.
Choice C rationale
Maintaining skin integrity and preventing infection are the most important goals in the care of a child with atopic dermatitis. The chronic inflammation and itching can lead to skin breakdown, increasing the risk of secondary bacterial or viral infections. Nursing interventions focus on gentle skin care, emollients, and managing itching.
Choice D rationale
Alcohol-based lotions should be avoided in children with atopic dermatitis as alcohol can dry and irritate the skin, exacerbating the condition and impairing skin integrity. Emollients that are fragrance-free and hypoallergenic are preferred to maintain skin hydration.
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