A nurse is assessing a client who is immediately postoperative following abdominal surgery. The nurse notes serosanguineous drainage on the dressing. Which of the following actions should the nurse take?

A. Speech pathologist: Infants who undergo cheiloplasty (surgical repair of a cleft lip) may experience difficulties with feeding, swallowing, and later speech development. Collaboration with a speech pathologist ensures the infant receives guidance on feeding techniques and early intervention for speech and language development.

B. Facility chaplain: While a chaplain can provide emotional and spiritual support to the family, they are not directly involved in the infant’s functional outcomes related to cheiloplasty. Their role is supportive rather than interventional for feeding or speech development.

C. Physical therapist: Physical therapy is not typically indicated after cheiloplasty unless there are unrelated musculoskeletal concerns. It does not address the primary needs related to feeding or speech associated with cleft lip repair.

D. Orthopedic specialist: An orthopedic specialist manages musculoskeletal conditions and would not be involved in the care or rehabilitation of an infant following cleft lip repair unless there were unrelated orthopedic issues.

A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.

B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.

C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.

D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.