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    Rn Hesi Pediatric And Women Health Proctored Exam
    Select All That Apply

    Exhibits The nurse is reviewing the assessment data. Which are the 3 most likely reasons that the infant is crying?

    Explanation & Rationale

    A. Separation anxiety: At 4 months, infants can experience mild distress when separated from their primary caregiver. Crying may indicate discomfort due to absence of the parent or familiar person. B. Hypoxia: The infant is pink, well-perfused, and has clear, equal breath sounds, making hypoxia an unlikely cause of crying at this time. C. Hemorrhage: The surgical site is clean, dry, and intact, and vital signs are stable, indicating that bleeding is unlikely to be causing the crying. D. Hypovolemia: The infant is receiving continuous IV fluids and shows no signs of poor perfusion or hypotension, making hypovolemia an unlikely cause. E. Opioid withdrawal: There is no indication the infant was exposed to opioids prenatally, so withdrawal is not a likely cause of crying. F. Hunger: Infants cry as a primary method of communicating hunger. Being NPO may contribute to discomfort and crying. G. Pain: Postoperative pain from fundoplication is a common and expected cause of crying in infants, even if vital signs are stable.

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