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: This is the correct choice. Aspirin is a part of the treatment for children with Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels. Aspirin is given to reduce fever, inflammation, and the risk of developing coronary artery aneurysms. Aspirin is usually given in high doses during the acute phase of the disease and then in low doses as a preventive measure until the inflammation subsides.
Choice B reason: This is not a good choice. Aspirin is not contraindicated for children with Kawasaki disease, unlike other conditions such as Reye syndrome or viral infections. Aspirin is a beneficial and essential part of the treatment for children with Kawasaki disease, as it can prevent serious and potentially fatal complications.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Delaying dental visits until the child's heart defect is fully repaired is not a recommended practice. Dental hygiene is important for preventing oral infections that can spread to the bloodstream and cause infective endocarditis. The child should have regular dental check-ups and cleanings, as well as good oral care at home.
Choice B reason: This is the correct choice. Administration of antibiotics one hour prior to all dental procedures is a critical teaching point to emphasize for parents of a child with a complex congenital heart defect. Dental procedures can cause bleeding and bacteria to enter the bloodstream, which can infect the damaged or abnormal heart valves and cause infective endocarditis. Antibiotics can prevent or reduce the risk of this complication by killing the bacteria before they reach the heart.
Choice C reason: This is not a good choice. Administration of daily prophylactic antibiotics is not a necessary or effective measure for preventing infective endocarditis in a child with a complex congenital heart defect. Daily antibiotics can cause side effects, such as allergic reactions, diarrhea, or yeast infections. They can also lead to antibiotic resistance, which can make the bacteria harder to treat if they do cause an infection.
Choice D reason: This is not a good choice. High dose IV antibiotics for 2-8 weeks is not a preventive strategy for infective endocarditis, but a treatment option for an established infection. IV antibiotics are given to eradicate the bacteria from the bloodstream and the heart valves and prevent further damage or complications. However, IV antibiotics are not always effective and may have serious s
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