Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
A child who is postoperative following surgical removal of a Wilms' tumorA nurse is caring for a child who is postoperative following surgical removal of a Wilms' tumor. Which of the following assessments should indicate to continue NPO status?
Correct answer
B
Rationale
The correct answer is B: Absent bowel sounds. This indicates decreased gastrointestinal motility, which can lead to complications like ileus postoperatively. Passing of flatus (choice A) every 30 min shows bowel function, so NPO status may not be necessary. Abdominal girth 1 cm larger than yesterday (choice C) may indicate bloating but not necessarily a reason to continue NPO. Report of pain at the operative site (choice D) is important to address but doesn't directly impact the need for NPO status.