A nurse is contributing to the plan of care for a client 48 hr following cesarean birth. Which of the following nonpharmacologic interventions should the nurse include to reduce pain from intestinal gas?

Provide the client with a carbonated beverage.

Encourage the client to lie on their right side.

Encourage the client to ambulate.

Provide the client with straws for beverages.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The nurse should provide the client with a carbonated beverage as a nonpharmacologic intervention to reduce pain from intestinal gas. Carbonated beverages, like soda or sparkling water, can help alleviate gas by promoting burping, which releases trapped gas from the digestive system. The effervescence of the carbonated drink can help relieve the discomfort caused by accumulated gas, offering relief to the client.

Choice B reason:

Encouraging the client to lie on their right side is not an effective nonpharmacologic intervention for reducing pain from intestinal gas. Although positioning can sometimes aid in relieving discomfort, lying on the right side does not specifically target the reduction of gas. Therefore, it is not the most appropriate choice in this scenario.

Choice C reason:

Encouraging the client to ambulate is a beneficial nonpharmacologic intervention for various post-operative conditions. However, when it comes to reducing pain from intestinal gas, it may not be as effective as other options. While movement can aid in gas passage through the digestive system, it might not be the most immediate or direct solution for alleviating the client's discomfort.

Choice D reason:

Providing the client with straws for beverages does not directly address the issue of intestinal gas. It is an unrelated intervention and may not provide any significant relief for the client's discomfort.

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Correct Answer is B

Explanation

Choice A reason:

Experiences separation anxiety - This is a common behavior seen in toddlers during hospitalization. Being away from their parents or caregivers and being in an unfamiliar environment can lead to feelings of anxiety and distress. Separation anxiety is a natural response for young children who rely on their primary caregivers for comfort and security.

Choice B reason:

Fears a loss of control - Toddlers may feel overwhelmed and fearful when they find themselves in a hospital setting. The loss of control over their daily routines and environment can be frightening for them. They may be unable to understand the reasons behind medical procedures or interventions, further increasing their anxiety.

Choice C reason:

Feels hospitalization is punishment - While some children might have difficulty understanding the reasons for hospitalization, it is less common for them to perceive it as punishment.

Children at this age often lack the cognitive capacity to associate their illness with punishment.

Choice D reason:

Develops body image disturbance - Body image disturbance is not a typical behavior observed in toddlers during hospitalization. This issue is more common in older children or adolescents who may experience changes in their appearance due to medical conditions or treatments.

A. Obtain vital signs. B. Stop the IV infusion. C. Administer epinephrine IM. D. Monitor intake and output.

Correct Answer is B

Explanation

Choice A reason:

Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.

Choice B reason:

Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.

Choice C reason:

Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.

Choice D reason:

Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.

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A nurse is contributing to the plan of care for a client 48 hr following cesarean birth. Which of the following nonpharmacologic interventions should the nurse include to reduce pain from intestinal gas?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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