Difficulty: Medium
Average Score: 67%
Simulated
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
Correct answer
B
Rationale
A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.