The nurse is caring for a 13-year-old who is 2 days post-operative from a laparoscopic appendectomy. Upon assessment, the nurse notes the following vital signs: 37,1°C (98.8°F), a pain rating of 3 out of 10, and breath sounds are diminished in the lower lobes. What action should the nurse take first?
Maintain prone positioning.
Request a laboratory prescription for a white blood cell count.
Administer prescribed acetaminophen.
Encourage the use of an incentive spirometer.
The Correct Answer is D
Rationale:
A. Prone positioning is not recommended post-operatively for abdominal surgery and could exacerbate respiratory issues.
B. While monitoring white blood cell count is important, encouraging lung expansion and preventing complications such as atelectasis is a more immediate priority.
C. The client's pain rating is low and does not necessitate immediate administration of acetaminophen.
D. Encouraging the use of an incentive spirometer helps improve lung expansion, which is crucial to prevent atelectasis and promote proper oxygenation, particularly when breath sounds are diminished.
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Correct Answer is B
Explanation
Rationale:
A. While newborns need to feed frequently, particularly breastfed infants, parents do not need to wake their baby for every feeding unless advised by their healthcare provider due to specific concerns like low birth weight.
B. After birth, the newborn receives initial vaccinations, such as the hepatitis B vaccine. The next set of vaccinations is typically administered at the 1 or 2-month check-up, so no additional immunizations are needed immediately after discharge.
C. Full head control is generally achieved by around 4 months of age, not 1 month.
D. Babies typically triple their birth weight by around 12 months of age, not by 4-6 months.
Correct Answer is D
Explanation
Rationale:
A. There is no need to notify the provider if urine output is within the normal range.
B. Oral rehydration may not be necessary if the child is adequately hydrated.
C. A bladder scan is not required if the urine output is within the normal range.
D. Continue to monitor the client as the urine output is within the normal range. For a 3-year-old child (15 kg), normal urine output is 1-2 mL/kg/hr. This child’s output is approximately 1.3 mL/kg/hr, which is normal.