A 10-month-old infant who has had a cleft palate repair returns to the nursing unit from surgery. Which of the following nursing actions demonstrates the most important priority for airway care?
Suctions mouth and nasopharyngeal passages.
Gives IV morphine for pain.
Cleans suture line with normal saline.
Elevates the head of the bed 30 degrees.
The Correct Answer is A
Choice A reason: This statement is correct, as suctioning the mouth and nasopharyngeal passages is the most important priority for airway care in an infant who has had a cleft palate repair. The nurse should suction the infant frequently and gently to remove any blood, mucus, or secretions that may obstruct the airway or cause aspiration. The nurse should also monitor the infant's respiratory rate, oxygen saturation, and signs of distress.
Choice B reason: This statement is incorrect, as giving IV morphine for pain is not the most important priority for airway care in an infant who has had a cleft palate repair. Although pain management is essential for the infant's comfort and recovery, it is not the first intervention for airway care. The nurse should assess the infant's pain level and administer the prescribed analgesics as needed, but only after ensuring the airway is clear and patent.
Choice C reason: This statement is incorrect, as cleaning the suture line with normal saline is not the most important priority for airway care in an infant who has had a cleft palate repair. Although wound care is important for the prevention of infection and the promotion of healing, it is not the first intervention for airway care. The nurse should clean the suture line with sterile saline or water as ordered, and avoid using cotton swabs or hydrogen peroxide that may damage the tissue or cause bleeding.
Choice D reason: This statement is incorrect, as elevating the head of the bed 30 degrees is not the most important priority for airway care in an infant who has had a cleft palate repair. Although elevating the head of the bed can help reduce the swelling and improve the drainage, it is not the first intervention for airway care. The nurse should position the infant on the side or abdomen, with the head slightly elevated, and avoid placing the infant on the back or putting pressure on the operative site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as Tanner staging is not based on chronological age, but on the physical development of the child. Children may enter and progress through puberty at different ages, depending on their genetic, environmental, and nutritional factors.
Choice B reason: This statement is incorrect, as Tanner staging is not based on the sexual behavior of the child, but on the appearance of the external genitalia, breasts, and pubic hair. Sexual behavior is influenced by many factors, such as social, cultural, and psychological factors, and does not necessarily correlate with the stage of puberty.
Choice C reason: This statement is incorrect, as Tanner staging is not based on the increase in height and weight, but on the maturation of the reproductive organs and secondary sex characteristics. Height and weight are affected by many factors, such as nutrition, health, and genetics, and do not necessarily reflect the stage of puberty.
Choice D reason: This statement is correct, as Tanner staging is based on the predictable stages of puberty that are based on primary and secondary sexual characteristics. Primary sexual characteristics are the development of the internal and external reproductive organs, such as the ovaries, testes, uterus, penis, and vagina. Secondary sexual characteristics are the changes that occur in other parts of the body, such as the breasts, pubic hair, axillary hair, voice, and body shape.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Adult heart disease can cause volume overload, but so can pediatric heart disease. Volume overload is a condition where the heart has to pump more blood than normal, which can lead to heart failure and pulmonary edema. Volume overload can be caused by various factors, such as valvular defects, hypertension, or anemia.
Choice B reason: This is the correct choice. Adult heart disease is usually acquired, meaning that it develops over time due to factors such as aging, lifestyle, or infection. Pediatric heart disease is usually congenital, meaning that it is present at birth due to genetic or environmental factors that affect the development of the heart.
Choice C reason: This is not a good choice. Heart failure can occur in both adult and pediatric heart disease. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, which can lead to symptoms such as fatigue, shortness of breath, and edema. Heart failure can be caused by various factors, such as coronary artery disease, cardiomyopathy, or arrhythmias.
Choice D reason: This is not a good choice. Digoxin is a drug that can be used for both adults and children with heart disease. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, slows down the heart rate, and improves the symptoms of heart failure. Digoxin can be used for conditions such as atrial fibrillation, heart failure, or congenital heart defects. However, digoxin has a narrow therapeutic range and requires careful monitoring of the blood levels and the patient's response.
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