Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?
1. Bloody urine
2. One void since returning from surgery
3. Bladder spasms responding to pharmacologic intervention
4. Double diapering from the previous shift
2
Explanation:
1. Bloody urine is expected in the immediate postoperative period.
2. A 10-month-old child will void more often than 1 time in 4 hours. This could indicate the stent is occluded. The surgeon should be notified.
3. This is a normal finding.
4. This is a desired finding and does not need to be reported to the surgeon.
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