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.

Measure the infant's weight daily.

Initiate short breastfeeding sessions 12 hr postoperatively.

Place the infant in prone position after feeding.

Fold the infant's diaper below the incision site.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Rationale:

• Measure the infant's weight daily: Daily weight monitoring is standard for postoperative infants to assess hydration status and overall recovery. Accurate weight helps guide fluid replacement and nutrition management.

• Initiate short breastfeeding sessions 12 hr postoperatively: Postoperative feedings usually begin relatively quickly (often 4-6 hours post-op) with small amounts of clear fluids or breast milk/formula, gradually increasing. 12 hours is an expected time frame to begin re-feeding/breastfeeding sessions.

• Place the infant in prone position after feeding: Infants are placed on their backs (supine) to reduce the risk of sudden infant death syndrome (SIDS). Prone positioning after feeding is not recommended in postoperative care unless specifically ordered for surgical reasons.

• Fold the infant's diaper below the incision site: Keeping the diaper below the surgical site prevents irritation, friction, or pressure on the incision, promoting healing and preventing infection. This is a standard nursing intervention after abdominal surgery in infants.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Rationale:

A. Contact: Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment, such as MRSA or C. difficile. Erythema migrans, associated with Lyme disease, is not spread through contact.

B. Droplet: Droplet precautions are for infections transmitted through large respiratory droplets, such as influenza or pertussis. Lyme disease does not spread via respiratory secretions, so droplet precautions are unnecessary.

C. Airborne: Airborne precautions apply to infections transmitted via small particles that remain suspended in the air, such as tuberculosis or measles. Lyme disease is not airborne, so this precaution is not required.

D. Standard: Standard precautions are appropriate for Lyme disease, including erythema migrans. These precautions involve routine hand hygiene, use of gloves when in contact with body fluids, and proper handling of contaminated materials, which are sufficient since the disease is transmitted via tick bites, not person-to-person.

A. Evaluate why the client was not ambulated. B. Ambulate the client on behalf of the AP. C. Supervise the AP performing the task. D. Remind the AP of her assigned tasks.

Correct Answer is A

Explanation

Rationale:

A. Evaluate why the client was not ambulated.: The first step in addressing a missed delegated task is to assess the reason it was not completed. Understanding whether barriers were related to the AP, client condition, workload, or communication helps the nurse plan corrective action and prevents recurrence.

B. Ambulate the client on behalf of the AP.: While ensuring the client’s needs are met is important, jumping straight to performing the task bypasses assessment of the underlying issue. Immediate action may address the symptom but not the cause of the missed delegation.

C. Supervise the AP performing the task.: Supervision is appropriate for ongoing tasks but is not the first action once a task has already been missed. The nurse must first determine why the task was not completed before implementing supervision.

D. Remind the AP of her assigned tasks.: Reminding the AP without assessing why the task was missed does not address potential systemic or situational barriers. It may be necessary later but is not the initial step in problem resolution.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

Correct Answer is D

Explanation

A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

The nurse is continuing to care for the child. Exhibits Select the 3 priority actions that the nurse should take.

A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

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