A nurse is monitoring a client who is 36 hrs postoperative following gastric banding. Which of the following findings should the nurse expect?

The client is voiding at least 250 mL/hr.

The client is maintaining bed rest.

The client is tolerating clear liquids.

The client is consuming 1.000 calories daily.

Answer and Explanation

The Correct Answer is C

A. The client is voiding at least 250 mL/hr. This amount is excessive and not typical. The expected urine output for an adult is at least 30 mL/hr, so 250 mL/hr could indicate overhydration or diuretic use, which is not expected postoperatively.
B. The client is maintaining bed rest. Early ambulation is encouraged after surgery to prevent complications like deep vein thrombosis and promote recovery. Bed rest 36 hours post-op is not expected unless medically indicated.
C. The client is tolerating clear liquids. After gastric banding, clients typically start with clear liquids and gradually progress to more solid foods. Tolerating clear liquids at 36 hours post-op is an expected and positive finding.
D. The client is consuming 1,000 calories daily. At this stage post-op, calorie intake is significantly restricted, often much lower than 1,000 calories. Intake gradually increases as the diet progresses from liquids to solids.

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Correct Answer is C

Explanation

A. Boil bottle rings and nipples for 10 min to ensure sanitization. Boiling for 10 minutes is excessive and can damage bottle parts. A boil time of 5 minutes is typically sufficient for sanitizing feeding equipment before first use.
B. Keep the newborn on a strict 3 hr feeding schedule. Newborns should be fed on demand, which may be more or less frequently than every 3 hours. Hunger cues should guide feeding to promote healthy growth and bonding.
C. Use bottles of refrigerated formula within 48 hr. Prepared formula should be refrigerated and used within 48 hours to ensure safety and prevent bacterial growth. This is a safe practice when storing formula that has not been fed to the infant.
D. Place the newborn on their abdomen for 30 min following each feeding. Placing a newborn on the abdomen increases the risk of sudden infant death syndrome (SIDS). Infants should always be placed on their backs to sleep.

A. First trimester bleeding B. Severe abdominal pain C. Nausea D. Delayed menses

Correct Answer is B

Explanation

A. First trimester bleeding. Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with miscarriage or ectopic pregnancy.
B. Severe abdominal pain. Abruptio placentae involves the premature separation of the placenta from the uterine wall, often leading to sudden, severe abdominal pain and possibly vaginal bleeding. It is a medical emergency requiring immediate attention.
C. Nausea. While nausea can occur during pregnancy, it is not a hallmark symptom of abruptio placentae and does not assist in differentiating it from other complications.
D. Delayed menses. Delayed menses may indicate early pregnancy, but it is not related to abruptio placentae, which occurs later in pregnancy.

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