A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?
Offer the toddler flavored gelatin.
Initiate oral rehydration therapy for the toddler.
Include chicken broth in the toddler's diet.
Feed the toddler the BRAT diet.
The Correct Answer is B
Rationale:
A. Offering flavored gelatin can provide some hydration, but it does not provide sufficient electrolytes necessary for rehydration in gastroenteritis.
B. Initiating oral rehydration therapy for the toddler is essential in treating dehydration caused by infectious gastroenteritis. Oral rehydration solutions contain the right balance of electrolytes and fluids to replenish losses.
C. While chicken broth may provide some fluid and salt, it is not as effective as a specific oral rehydration solution tailored for children with gastroenteritis.
D. The BRAT diet (bananas, rice, applesauce, and toast) is no longer recommended as the primary diet for children with gastroenteritis, as it does not provide adequate nutrition or electrolytes.
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Correct Answer is A
Explanation
Rationale:
A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.
B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.
C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.
D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.
Correct Answer is B
Explanation
Rationale:
A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.
B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.
C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.
D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.