A nurse is preparing to administer an IM injection for an infant. Which of the following actions should the nurse take?

Rationale:

A. Provide 60 mL (2 oz) of fluid intake every 5 min.: Following gastric bypass surgery, the stomach pouch is very small and cannot tolerate large or frequent volumes. Giving 60 mL every 5 minutes places the client at high risk for nausea, vomiting, dumping syndrome, and anastomotic complications. Fluid intake must be introduced slowly in small sips.

B. Ambulate the client 48 hr after the procedure.: Early ambulation is essential to prevent postoperative complications such as atelectasis, venous thromboembolism, and delayed return of bowel function. Waiting 48 hours is too long; clients should begin ambulating on the day of surgery or within the first 24 hours to promote circulation.

C. Provide a soft diet on the first postoperative day.: After gastric bypass surgery, the digestive system needs time to heal and cannot tolerate solid or semi-solid foods. Clients begin with clear liquids and progress gradually to pureed, soft, and then solid diets over several weeks.

D. Measure and compare abdominal girth daily.: Monitoring abdominal girth helps detect postoperative complications such as internal bleeding, leaks, or ileus, which may present with distention or increased abdominal size. Regular measurement provides early recognition of changes that require prompt intervention.

Rationale:

A. "You have the right to decide who receives information.": Clients have the legal and ethical right to confidentiality regarding their medical care under HIPAA and patient privacy regulations. Respecting the client’s decision about who can receive health information reinforces autonomy and ensures that the nurse supports the client’s rights in healthcare decision-making.

B. "Your partner can be a great source of support for you at this time.": While acknowledging the potential benefits of support is empathetic, this statement does not address the client’s request for privacy. It may inadvertently pressure the client to share information, which could violate confidentiality and autonomy.

C. "Is there a reason you don't want your partner to know about your procedure?": Asking for justification may make the client feel challenged or judged. The client is not required to explain their choice, and pressing for reasons can undermine trust and respect for their privacy.

D. "The provider will be tactful when talking to your partner.": This statement assumes the provider will communicate with the partner and disregards the client’s expressed wishes. It could lead to disclosure against the client’s consent, violating confidentiality and patient rights.