Author Question: A 3-year-old is hospitalized following surgery for a ruptured appendix.During assessment of the ... (Read 55 times)

jhjkgdfhk · **on:** Jun 27, 2018

A 3-year-old is hospitalized following surgery for a ruptured appendix.During assessment of the child,the nurse notes that the child is sleeping. Vital signs are as follows:

Temperature 97.8F axillary,Pulse 90,
Respirations 12,and Blood pressure 100/60.Based on this assessment,the nurse concludes that the child is
1. comfortable and the pain iscontrolled.
2. in shock secondary to blood lossduring surgery.
3. experiencing respiratory depressionsecondary to opioid administration for postoperative pain.
4. sleeping to avoid pain associatedwith surgery.

Question 2

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dl to 16.6 mg/dl in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?

1. Continue to observe.
2. Begin phototherapy.
3. Begin blood exchange transfusion.
4. Stop breastfeeding.

ladyjames123 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

Answer:3
Rationale:Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a
3-year-old. The other vital signs are within normal limits for a sleeping 3-year-old.

Answer to Question 2

2
Rationale 1: Physiologic jaundice is normal, but will need to be treated.
Rationale 2: Physiologic jaundice is normal, but will need to be treated. Phototherapy might be required if the serum bilirubin level increases by more than 0.2 mg/dl per hour.
Rationale 3: Newborns with a bilirubin of 20 mg/dl or above might need a blood exchange transfusion.
Rationale 4: The newborn may continue to breastfeed.