The nurse is caring for an infant immediately after pyloromyotomy surgery has been performed to treat pyloric stenosis. The infant’s parents are understandably anxious about their child. Given the situation, what is the most appropriate way for the nurse to position the infant during the anesthesia recovery period?
Place the infant on the back.
Support the infant and place them on their side.
Lay the infant on their stomach.
Allow the parents to hold their infant.
The Correct Answer is B
Choice A reason: Placing the infant on the back post-pyloromyotomy risks aspiration during anesthesia recovery, as vomiting is common with pyloric stenosis. Side-lying positioning ensures airway protection, making this unsafe and incorrect for managing the infant’s recovery period effectively after this surgical procedure.
Choice B reason: Positioning the infant on their side with support prevents aspiration and maintains airway patency post-pyloromyotomy, addressing vomiting risks from pyloric stenosis. This aligns with postoperative pediatric nursing standards, making it the most appropriate position during anesthesia recovery for the infant.
Choice C reason: Laying the infant on the stomach is unsafe post-surgery, increasing aspiration and pressure on the surgical site. Side-lying positioning protects the airway and incision, making this incorrect for the infant’s recovery period following pyloromyotomy for pyloric stenosis in the hospital setting.
Choice D reason: Allowing parents to hold the infant may comfort but risks disrupting surgical recovery or airway management during anesthesia effects. Side-lying positioning ensures safety, making this less controlled and incorrect for the immediate postoperative period in this surgical context for the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Discussing care options involves clinical judgment, which is the nurse’s responsibility, not delegable to family. Providing comfort tasks like swabs or pads is appropriate, making this incorrect, as it involves professional decision-making unsuitable for family delegation in the adolescent’s care.
Choice B reason: Keeping medical equipment like a blood pressure cuff involves monitoring, a nursing task, not delegable to family. Comfort tasks like providing swabs or pillows are suitable, making this incorrect, as it requires clinical skills beyond family’s role in the terminally ill adolescent’s care.
Choice C reason: Supplying mouth swabs for lip moistening is a simple comfort task family can perform, promoting involvement and patient comfort. This aligns with pediatric palliative care delegation, making it a correct intervention to delegate to family for the terminally ill adolescent’s care.
Choice D reason: Providing disposable pads for hygiene is a non-clinical task family can manage, supporting dignity and comfort. This aligns with family involvement in palliative care, making it a correct intervention to delegate for the terminally ill adolescent’s care in the hospital setting.
Choice E reason: Supplying pillows for repositioning is a comfort-focused task family can handle, enhancing the adolescent’s well-being. This aligns with pediatric palliative care principles, making it a correct intervention to delegate to family members for the terminally ill adolescent’s hospital care.
Correct Answer is D
Explanation
Choice A reason: Calling the police directly bypasses hospital protocol for suspected abuse. Contacting social services allows for a multidisciplinary evaluation of the inconsistent spiral fracture story, ensuring appropriate investigation, making this premature and incorrect compared to following hospital child protection procedures for the child.
Choice B reason: Informing the hospital administrator is less direct than contacting social services, which is trained to handle suspected abuse cases. The inconsistent injury story requires specialized assessment, making this less appropriate and incorrect for addressing the immediate concern of potential child maltreatment in the ER.
Choice C reason: Confronting the caregiver risks escalating the situation and may hinder investigation. Reporting to social services ensures a professional evaluation of the implausible injury explanation, aligning with child protection protocols, making this confrontational approach incorrect for managing suspected abuse in the hospital setting.
Choice D reason: Calling social services is the appropriate action for a spiral fracture with an inconsistent story, as it suggests possible abuse. Social services can investigate and coordinate with authorities, aligning with hospital protocols for child maltreatment, making this the correct response to ensure the child’s safety.
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