A nurse is caring for a newborn with bladder exstrophy. Which nursing intervention is the highest priority in the immediate postoperative period following primary closure?

The single most critical intervention in the immediate postoperative period is maintaining strict sterile technique during all manipulation of urinary drainage catheters or stents. These tubes provide a direct portal for bacteria to ascend into the newly reconstructed, highly vascular bladder. A breach in sterility can precipitate a urinary tract infection, urosepsis, or wound dehiscence, directly jeopardizing the long-term goals of urinary continence and renal preservation.

The infant must be kept immobilized postoperatively to prevent tension on the pubic bone approximation and abdominal closure. Legs are often maintained in adduction, and the child may be placed in modified Bryant's traction or a spica cast. Avoid any abduction of the hips. Early ambulation is strictly contraindicated.

Adequate analgesia and sedation are essential to minimize crying and straining, which increase intra-abdominal pressure and can stress the suture lines. A combination of scheduled acetaminophen and opioid infusions is commonly used. Assess pain using a validated neonatal scale and titrate medications to maintain comfort while ensuring respiratory stability.

Oral feedings are typically withheld in the initial postoperative phase due to the risk of ileus and the need for bowel rest. Nutrition is provided via total parenteral nutrition (TPN) or IV fluids until bowel function returns. Nasogastric tube decompression may be necessary to prevent abdominal distention.

The surgical site must be kept clean and dry. Apply a protective barrier to the skin surrounding the incision to prevent excoriation from urine or drainage. Do not apply heat or topical agents unless specifically ordered by the surgical team, as these can macerate the wound or introduce infection. Monitor for signs of dehiscence, infection, or skin breakdown.

Prepare parents for the appearance of the surgical site, immobilization devices, and multiple lines and tubes. Emphasize the critical role of hand hygiene and limiting visitors to prevent infection. Provide emotional support and reinforce that the intense postoperative precautions are temporary and essential for a successful long-term outcome.