A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?

Offer sips of water 4 hr following surgery.

Assist the adolescent to ambulate 12 hr following surgery.

Maintain the head of the bed at a 30° angle.

Ensure two nurses logroll the adolescent every 2 hr.

Answer and Explanation

The Correct Answer is D

A.   Offering sips of water 4 hours following surgery may be too early and could increase the risk of postoperative complications such as nausea and vomiting.
B.   Assisting the adolescent to ambulate 12 hours following surgery may be too early depending on the surgical procedure and the adolescent's condition.
C.   Maintaining the head of the bed at a 30° angle is incorrect because this position increases pressure on the spinal cord and can cause complications.
D.   Logrolling the adolescent every 2 hours prevents spinal injury and promotes healing by keeping the spine in alignment

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Correct Answer is C

Explanation

A. Allowing the infant to cry before feeding increases energy expenditure and may worsen fatigue in infants with heart failure.
B. A recumbent position can increase the risk of aspiration; a semi-upright position is preferred.
C. Implementing a 3-hour feeding schedule ensures the infant receives adequate nutrition without excessive fatigue.
D. Feedings should be limited to 30 minutes to prevent excessive energy expenditure.

A. Place the child in a prone position. B. Clear the area of hard objects. C. Insert a tongue blade between the teeth. D. Minimize movement of the limbs.

Correct Answer is B

Explanation

Rationale:
A) Placing the child in a prone position can obstruct the airway and increase the risk of aspiration.
B) Clearing the area of hard objects helps prevent injury during a seizure.
C) Inserting a tongue blade between the teeth can cause oral trauma and should be avoided.
D) Minimizing movement of the limbs is not necessary during a seizure; the focus should be on ensuring safety and preventing injury.

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A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?

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