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 A
Explanation
Have a child life specialist explain the procedure using a doll.
Choice A rationale:
Having a child life specialist explain the procedure using a doll is the best approach for preparing a 4-year-old for a bone marrow aspiration. This method utilizes play therapy to help the child understand the procedure in a developmentally appropriate and non-threatening way.
Choice B rationale:
Giving the client color handouts might not effectively engage a 4-year-old's attention and understanding. Young children often benefit more from interactive and visual methods like using a doll.
Choice C rationale:
Telling the client that other children have had the procedure might not alleviate the child's anxiety or fear. Concrete explanations and visual aids are more effective in reducing anxiety and helping the child cope.
Choice D rationale:
Allowing the patient to watch a video of the procedure on another child could potentially increase anxiety and fear. Children might not fully comprehend the video and could misinterpret it, leading to more distress. Interactive methods are more effective.
Correct Answer is D
Explanation
Choice A rationale:
Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.
Choice B rationale:
Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.
Choice C rationale:
Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.
Choice D rationale:
Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.
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