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Plan to administer a plain water enema and maintain contact precautions is incorrect because pyloric stenosis is not an infectious condition and does not require contact precautions. Enemas, especially plain water enemas, are contraindicated in infants due to the risk of causing severe electrolyte imbalance and water intoxication. This intervention does not address the underlying problem of vomiting and dehydration.

Measure the infant's head circumference and weigh the infant is incorrect because although weight monitoring is part of routine assessment, head circumference measurement is not a priority in the context of acute dehydration from pyloric stenosis. The immediate concern is stabilizing fluid and electrolyte status.

Offer the infant small, frequent feedings of thickened liquids is incorrect because infants with pyloric stenosis are typically NPO until after surgical correction. Continuing oral feedings would worsen vomiting and further dehydrate the infant. Feeding modifications are not an appropriate intervention at this stage.

One artery and one vein is incorrect because a normal umbilical cord contains three vessels, not two. A cord with a single artery and one vein indicates a condition known as a single umbilical artery (SUA). SUA is associated with an increased risk of congenital anomalies such as renal malformations, cardiac defects, and chromosomal abnormalities. Therefore, while it can occur, it is not the expected or normal finding during a routine assessment after delivery.

Two veins and one artery is incorrect because fetal circulation includes only one umbilical vein. The umbilical vein is responsible for transporting oxygenated blood from the placenta to the fetus. Having two veins is not part of normal development and would represent a vascular abnormality rather than a normal anatomical structure.

Two arteries and two veins is incorrect because a four-vessel umbilical cord is not physiologically normal. This would indicate a rare congenital anomaly and is not the expected finding during a routine postpartum cord assessment.

Laxatives are contraindicated for postpartum clients is incorrect because laxatives are not universally contraindicated in the postpartum period. While strong stimulant laxatives may be used cautiously, many postpartum clients, especially those recovering from vaginal tears, episiotomies, or cesarean births, are safely prescribed stool softeners such as docusate sodium. These help prevent straining, which could increase pain or disrupt healing. Therefore, stating that all laxatives are contraindicated is inaccurate.

Daily enemas are needed to relieve constipation is incorrect because enemas are not recommended as a routine measure postpartum. Frequent enemas can irritate the rectal mucosa, cause electrolyte imbalance, and create dependency. They are reserved only for severe constipation and used only under provider supervision. Teaching a client to rely on daily enemas is inappropriate and potentially harmful.

Avoid fiber-rich foods, as they can worsen constipation is incorrect because fiber plays a key role in promoting regular bowel movements. Fiber adds bulk to stool, stimulates peristalsis, and improves stool consistency. Postpartum clients are encouraged to consume whole grains, fruits, vegetables, and legumes to help restore normal bowel habits. Avoiding fiber would likely worsen constipation rather than alleviate it.

Consoling the child is incorrect because soothing the infant does not address the underlying physiologic cause of the acute cyanosis and irritability. These symptoms indicate a hypercyanotic episode (tet spell), a medical emergency caused by a sudden increase in right-to-left shunting in tetralogy of Fallot. Simply consoling the infant will not improve oxygenation or reduce the degree of cardiac shunting.

Administering morphine is an appropriate intervention during a tet spell because morphine helps reduce infundibular spasm, decreases agitation, and lowers oxygen demand. However, while beneficial, it is not the immediate priority since positioning the child provides more rapid physiologic improvement and can be implemented instantly without a medication order or delay.

Providing supplemental oxygen is helpful because oxygen acts as a pulmonary vasodilator and can improve oxygen saturation during a tet spell. However, oxygen alone does not correct the primary problem, which is the acute increase in right-to-left shunting due to decreased pulmonary blood flow. While supplemental oxygen should be applied promptly, it is not the first priority intervention.

The mitral valve is located between the left atrium and left ventricle, and its atypical placement is not involved in TOF. TOF affects the right side of the heart and the outflow to the lungs, so attributing the condition to the mitral valve is misleading and incorrect.

TOF involves four defects, not three. The defects listed in this option (aortic stenosis, atrial septal defect, left ventricular hypertrophy) are unrelated to TOF. Aortic stenosis affects left ventricular outflow, atrial septal defect involves the atria rather than the ventricles, and left ventricular hypertrophy occurs in conditions affecting the left heart, not TOF. This option conflates other congenital heart defects with TOF.

While TOF does involve mixing of oxygenated and deoxygenated blood, the mixing occurs at the ventricular level due to the VSD, not at the atrial level. Describing the condition as caused by an atrial septal defect misrepresents the anatomy and pathophysiology of TOF. It may lead to misunderstanding about the location and severity of the defect.

Fever, decreased urine output, and refusal of oral liquids are concerning findings that may indicate dehydration or infection. Fever is a common post-operative response and usually peaks 1–3 days after surgery. Decreased urine output suggests the child may not be adequately hydrated, and refusal to take oral fluids can exacerbate this. While these findings warrant prompt attention and intervention, they are not immediately life-threatening in the immediate post-tonsillectomy period. Nursing interventions may include encouraging oral fluids, monitoring hydration status, and notifying the provider if the child’s output continues to decrease or fever persists.

Postoperative pain is expected after a tonsillectomy and can usually be managed with prescribed analgesics. While pain management is important to maintain comfort and prevent complications such as poor oral intake, pain alone is not considered a priority over signs of acute complications like hemorrhage. The nurse should assess pain, administer analgesics as prescribed, and monitor the child’s response, but this is not immediately life-threatening.

Enlarged cervical lymph nodes may indicate infection or inflammation, which is a common finding after tonsillectomy due to local tissue trauma or preexisting infection. While this may require monitoring and follow-up, it does not pose an immediate risk to airway or circulation, and therefore is not the highest priority in the acute postoperative period.

Although this client is hemorrhaging with a fetal demise, emergent cesarean delivery is not indicated when the fetus has already died. The priority is maternal stabilization and vaginal delivery if possible. Cesarean section in the presence of fetal demise is reserved for maternal indications only, such as uncontrolled bleeding or uterine rupture, which is not explicitly stated here.

This client is at 32 weeks but has stable maternal vital signs and a category I fetal heart tracing, indicating no fetal compromise. Immediate cesarean section is not warranted; careful monitoring and supportive care are appropriate. Delivery may be planned based on gestational age, maternal stability, and severity of abruption.

Although the client is at term with a fetal demise, emergent cesarean is not indicated. The priority is maternal safety, and vaginal delivery is preferred unless there is uncontrolled maternal hemorrhage or other complications. Cesarean would increase maternal surgical risk without benefiting the fetus.

An inguinal hernia occurs when abdominal contents protrude through the inguinal canal. Typical findings include a painless or tender groin or scrotal bulge, which may become incarcerated or strangulated, leading to vomiting or abdominal distention. Blood and mucus in the stool are not characteristic of inguinal hernia.

Tracheoesophageal fistula (TEF) is a congenital connection between the trachea and esophagus. Infants with TEF often present with coughing, choking, cyanosis, and excessive drooling during feeding. Stools mixed with blood and mucus are not associated with TEF.

Hypertrophic pyloric stenosis (HPS) is a condition in which the pyloric muscle thickens, causing gastric outlet obstruction. Classic symptoms include projectile, non-bilious vomiting, dehydration, and a palpable “olive-shaped” mass in the abdomen. Blood in the stool is not typical for HPS.