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:

A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.

B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.

C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.

D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.

Rationale:

A. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.

B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.

C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.

D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.