The nurse is caring for an infant with Hirschsprung’s disease who just returned from surgery for a laparoscopically assisted endorectal pull-through procedure.
The nurse must monitor which of the following orders?
NPO until bowel sounds return.
Apply barrier cream to diaper area.
Assess surgical site every 2 hours.
Monitor rectal temperature every 8 hours.
The Correct Answer is A
Choice A rationale
After a laparoscopically assisted endorectal pull-through procedure for Hirschsprung’s disease, it is important to monitor for the return of bowel sounds. This indicates that the gastrointestinal tract is starting to recover and function again after surgery. Until bowel
sounds return, indicating that peristalsis has resumed, the child should remain NPO (nothing by mouth) to prevent vomiting and aspiration.
Choice B rationale
Applying barrier cream to the diaper area is generally good practice for infants to prevent diaper rash, but it is not specifically related to the care of a child who has just undergone surgery for Hirschsprung’s disease.
Choice C rationale
While it is important to assess the surgical site regularly to check for signs of infection or complications, this does not need to be done every 2 hours. A more typical frequency might be every 4 to 8 hours, depending on the child’s condition and hospital policy.
Choice D rationale
Monitoring rectal temperature every 8 hours is not specifically related to the care of a child who has just undergone surgery for Hirschsprung’s disease. While it is important to monitor for fever as a sign of infection, temperature can usually be measured less invasively.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Adding a school breakfast program is a crucial step in promoting health and wellness in schools. It ensures that all students, regardless of their socioeconomic status, start their day with a nutritious meal. This can improve their concentration, cognitive function, and academic performance.
Choice B rationale
Reducing saturated fat in the school lunch offering is another important measure. High intake of saturated fats is associated with increased risk of heart disease and obesity. By offering meals low in saturated fats, schools can help instill healthy eating habits in students.
Choice C rationale
Calorically sweetened beverages are not recommended for inclusion in school health and wellness programs. These beverages are high in sugar and can contribute to obesity, tooth decay, and other health problems.
Choice D rationale
Making fruits or vegetables available with all meals is a key part of a balanced diet. They provide essential vitamins, minerals, and dietary fiber, and their consumption can help prevent chronic diseases.
Choice E rationale
Offering after-school physical fitness activities can help students meet the recommended levels of physical activity, improve their physical fitness, and reduce the risk of obesity. These activities also provide opportunities for social interaction and skill development.
Correct Answer is B
Explanation
Choice A rationale
An eight-year-old child who weighs 60 pounds, rides a bike without training wheels, and is an active swimmer is showing appropriate developmental milestones for their age. Riding a bike and swimming are complex activities that require good motor coordination and balance. These activities also indicate that the child is physically active, which is beneficial for overall health.
Choice B rationale
A three-year-old child who weighs 28 pounds, requires help with feeding, dislikes most foods, and refuses to drink milk may be showing signs of a feeding disorder or picky eating, which can lead to nutritional deficiencies and impact growth and development. This child requires further evaluation to determine the cause of these feeding difficulties and to develop a plan to address them.
Choice C rationale
A six-month-old who weighs 16 pounds, continues to breastfeed, has started solid foods, and is beginning to crawl is showing appropriate developmental milestones for their age. The World Health Organization recommends exclusive breastfeeding for the first six months of life, followed by the introduction of appropriate complementary foods. Crawling is also a typical developmental milestone that usually appears between 6 and 10 months of age.
Choice D rationale
A four-year-old child who weighs 40 pounds, eats from the same plate every meal, and is occasionally a picky eater is within normal behavior for their age. It’s common for
preschoolers to have food preferences and to want routines, such as using the same plate. Picky eating is also a common behavior at this age and usually isn’t a cause for concern unless it leads to nutritional deficiencies or other health problems.
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