A nurse is reinforcing teaching with a caregiver about how to safely prepare formula for their 3-day-old newborn. Which of the following statements should the nurse include in the teaching?

Rationale:

A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.

B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.

C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.

D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.

Rationale:

• Administer aspirin for fever: Aspirin can increase circulating thyroid hormones by displacing T4 and T3 from protein-binding sites. In a hyperthyroid or recently post-thyroidectomy patient, this may precipitate or worsen a thyroid storm. Acetaminophen is a safer antipyretic choice.

• Apply cooling blanket: The client’s postoperative fever (38.3°C), elevated heart rate (98/min), and history of hyperthyroidism indicate a risk for thyroid storm. External cooling is a supportive measure to manage hyperthermia during this critical period.

• Monitor vital signs every 4 hours: This is anticipated to detect signs of complications such as thyroid storm, hemorrhage, or airway compromise. Postoperative clients require close observation to identify early changes in temperature, pulse, or respiration.

• Place client on telemetry: Cardiac monitoring is essential after thyroidectomy in clients with a history of hyperthyroidism. Increased metabolic demand, fever, and potential for arrhythmias justify continuous cardiac observation.

• Palpate thyroid area to assess for hematoma: A neck hematoma is a potentially life-threatening complication of thyroid surgery. It can lead to airway obstruction. Palpation and inspection for swelling or firmness around the incision site are critical nursing assessments.