A nurse is caring for a 5-week-old infant who has just returned from a PACU following surgery.

Exhibits

The nurse is planning care for a 5-week-old infant who is postoperative. For each intervention, click to specify if the intervention is expected or unexpected for the infant. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale for correct choices

• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.

• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.

Rationale for incorrect choices

• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.

• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.

• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.

• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.

Rationale:

A. Administer pancreatic enzymes with meals: Pancreatic enzymes are used to aid digestion in clients with pancreatic insufficiency, not for epiglottitis. This intervention is unrelated to the acute respiratory management required for this condition.

B. Carefully suction the child's oropharynx to remove secretions: Suctioning the oropharynx in a child with epiglottitis can trigger laryngospasm and complete airway obstruction. Suctioning should be avoided unless absolutely necessary and performed only by experienced personnel with emergency airway equipment ready.

C. Continuously monitor the child's respiratory status: Epiglottitis can rapidly progress to airway obstruction. Continuous assessment of respiratory rate, effort, oxygen saturation, and signs of distress is critical to detect deterioration early and initiate emergency interventions, making this a priority nursing action.

D. Instill normal saline drops to nares before meals: Nasal saline drops are used to relieve mild nasal congestion and facilitate feeding in children but do not address the life-threatening airway risk in epiglottitis. This is a supportive measure, not a priority intervention.