A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Rationale for correct choices

• Laxative: The client is postoperative day 3 and reports not having had a bowel movement, which is common after abdominal surgery due to anesthesia, opioid use, and decreased mobility. The return of flatus indicates partial return of bowel function, making a laxative appropriate to stimulate bowel evacuation. Early management helps prevent postoperative ileus and discomfort.

• Bowel movements: Absence of bowel movements by postoperative day 3 signals delayed gastrointestinal motility. This finding indicates the need for intervention to promote normal elimination. Monitoring bowel movement patterns helps guide appropriate pharmacologic and nonpharmacologic interventions.

• Bowel sounds: The client has hypoactive bowel sounds, suggesting slowed intestinal activity following surgery. Hypoactive sounds combined with lack of bowel movement indicate decreased peristalsis rather than obstruction. This assessment finding supports the use of a laxative once flatus is present.

Rationale for incorrect choices

• Antiemetic: The client is not currently reporting nausea or vomiting. Gastrointestinal symptoms are related to decreased motility rather than upper GI upset. An antiemetic would not address constipation or delayed bowel function.

• Antidiarrheal: The client does not have diarrhea and has not had any bowel movements. Using an antidiarrheal would further slow intestinal motility and worsen constipation. This intervention would be inappropriate in the current postoperative context.

• Findings at incision site: Although purulent drainage and swelling suggest possible infection, these findings do not indicate the need for a laxative. Incisional findings are more relevant to antibiotic therapy or wound management. They do not explain delayed bowel elimination.

• Abdominal distention: The abdomen is soft and nondistended on assessment. Distention would suggest gas or obstruction, which is not present. The primary indicators remain bowel sounds and bowel movement status.

• Incisional tenderness: Incisional tenderness is expected after abdominal surgery and reflects tissue healing or inflammation. It does not directly influence bowel motility or elimination. Pain alone does not justify laxative use. This finding is unrelated to gastrointestinal function.

A. Fax the client's name and identifiable information to the rehabilitation facility: Faxing client information without encryption or secure transmission can expose sensitive data to unauthorized individuals. This does not fully protect confidentiality under HIPAA regulations.

B. Provide a verbal report of the client's condition to the paramedic performing the transfer: Sharing necessary health information directly with authorized personnel involved in the client’s care is appropriate and protects confidentiality. Verbal handoff ensures the receiving team has critical information while limiting exposure to unauthorized parties.

C. Email the client's health information to the facility in an unencrypted file: Sending unencrypted health information via email is unsafe and violates HIPAA guidelines. Unauthorized access could compromise the client’s privacy and confidentiality.

D. Discuss the client's response to the transfer with another staff nurse: Discussing the client’s health information with staff members not directly involved in the transfer or care constitutes a breach of confidentiality. Only pertinent staff members should receive the information.