A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?
Encourage attachment.
Minimize crying.
Restrict oral intake.
Initiate range of motion.
The Correct Answer is B
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Strict isolation should begin immediately after exposure. This choice is incorrect because chickenpox does not require strict isolation immediately after exposure. The incubation period of chickenpox is about 10-21 days, during which communicability has not yet begun.
Choice B rationale:
Communicability begins prior to the eruption of lesions. This choice is correct. Chickenpox is highly contagious, and individuals can transmit the virus to others even before the characteristic skin lesions appear. This understanding is crucial for appropriate room assignment to prevent the spread of the virus to other patients.
Choice C rationale:
Strict isolation should begin as soon as the skin lesions erupt. This choice is incorrect. While isolation precautions are necessary for patients with active chickenpox lesions, waiting until the lesions erupt is not sufficient to prevent transmission, as communicability starts before this stage.
Choice D rationale:
Communicability begins 14 days after exposure. This choice is incorrect. The correct timing for the onset of communicability is much earlier than 14 days after exposure. Waiting until this point for isolation would not effectively prevent transmission.
Correct Answer is B
Explanation
Choice A rationale:
The statement "I will not take medications in front of my child”. is correct. Caregivers should avoid taking medications in front of children to prevent them from mimicking the behavior, as some medications can be harmful if ingested accidentally.
Choice B rationale:
The statement "I will keep all my medications in my purse”. is incorrect. Keeping medications in a purse or easily accessible place poses a risk of accidental ingestion by the child. Medications should be stored out of reach and in child-resistant containers.
Choice C rationale:
The statement "We will safety-proof the grandparents' house”. is correct. Safety-proofing the environment is important to prevent accidental poisoning. This statement demonstrates caregiver awareness of potential risks in another household.
Choice D rationale:
The statement "We will put locks on all of our cabinet doors at home”. is correct. Locking cabinet doors is a preventive measure to keep children away from potentially harmful substances, showcasing the caregiver's understanding of safety precautions.
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