A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which of the following nursing interventions would the nurse omit from the plan of care for this child?
1. Frequent assessment of the surgical site
2. N.p.o. status until bowel sounds return
3. Monitor rectal temperature every hour.
4. Allow parents at the bedside as soon as possible.
3
Rationale:
1. The surgical site must be visualized frequently for bleeding.
2. This is standard postop care.
3. Rectal temperature is not indicated, and should never be done as frequently as q1h.
4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.
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