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 A
Explanation
Choice A reason: The squeeze bottle and ESSR method of feeding are recommended for infants with cleft lip and palate as they allow for better control of the flow and volume of the formula, prevent air swallowing and aspiration, and promote oral stimulation and development.
Choice B reason: Supplemental feeding through an N/G tube is not usually necessary for infants with cleft lip and palate unless they have severe feeding difficulties, failure to thrive, or other complications. The goal is to promote oral feeding as much as possible.
Choice C reason: Adding rice cereal to the formula is not advised for infants with cleft lip and palate as it can increase the risk of aspiration, choking, and infection. Rice cereal can also interfere with the absorption of iron and other nutrients from the formula.
Choice D reason: Infants with cleft lip and palate usually have a hard time breastfeeding as they cannot create a proper seal and suction with the nipple. Breastfeeding may be possible with some modifications and support, but it is not the norm.
Correct Answer is D
Explanation
Choice A reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause is unknown, but it may be related to genetic, environmental, or hormonal factors.
Choice B reason: Slow feeding will not be sufficient to manage hypertrophic pyloric stenosis. The infant will have persistent vomiting, dehydration, and weight loss due to the obstruction of the pylorus.
Choice C reason: Dietary restrictions will not be effective for hypertrophic pyloric stenosis. The infant will not be able to tolerate any oral intake until the pylorus is surgically corrected.
Choice D reason: Surgery will be necessary to treat hypertrophic pyloric stenosis. The surgery is called pyloromyotomy, which involves cutting the thickened muscle of the pylorus to allow the stomach to empty into the duodenum.
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