A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

1. Apply warm compresses to the incision site
Contraindicated
Applying warm compresses directly to the surgical site, especially in a perineal prostatectomy, could potentially increase the risk of infection or cause increased swelling in the surgical area. The incision site is still healing, and local heat could increase blood flow, which might lead to complications like bleeding or infection.
2. Administer enema to relieve constipation

Anticipated
The client reports abdominal cramping and small, hard, painful bowel movements, which are signs of constipation. Enemas are commonly used to relieve constipation and to prevent straining that could stress the perineal surgical site or cause hemorrhoidal irritation. The use of an enema is appropriate in this case to help alleviate the client's symptoms.
3. Irrigate indwelling urinary catheter with 50 mL of normal saline

Anticipated
After prostatectomy, clients often have an indwelling urinary catheter for urinary drainage. Irrigating the catheter can help prevent clogging and maintain proper drainage. Normal saline is a sterile solution and would help ensure the catheter is patent, which is particularly important for preventing urinary retention or infection.
4. Place a blanket roll under the client's knees while in bed

Anticipated
Placing a blanket roll under the client’s knees helps to maintain a comfortable position, which can promote venous return and reduce pressure on the perineum and lower back. This position is also beneficial for alleviating perineal pain after prostate surgery.
5. Maintain bed rest for 2 days postoperatively

Contraindicated
The client has already demonstrated the ability to ambulate independently and transfer out of bed to a chair. Prolonged bed rest after surgery is generally discouraged unless there are specific complications (e.g., excessive bleeding, infection). Early ambulation is encouraged to prevent DVT, promote circulation, and prevent complications such as atelectasis and constipation.

A. Instructing the client to avoid coughing during the procedure is important to prevent disrupting the needle placement during the thoracentesis.
B. The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.
C. Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.
D. The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.