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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

The statement "The parent collects the specimen when the child reports itching”. is incorrect. The scotch tape test for pinworms involves placing clear tape on the perianal area in the morning to collect eggs that may have been laid during the night, not based on itching.

Choice B rationale:

The statement "The parent collects the specimen in the evening before the child goes to bed”. is incorrect. The test is most effective in the morning when the child wakes up, as this is when pinworms are most active and lay their eggs.

Choice C rationale:

The statement "The parent collects the specimen after the child has had a bowel movement”. is incorrect. The test doesn't involve collecting a specimen after a bowel movement but rather in the morning using transparent tape to catch pinworm eggs.

Choice D rationale:

The statement "The parent collects the specimen in the morning when the child awakens”. is correct. This is the correct time for the scotch tape test, as it maximizes the chance of detecting pinworm eggs laid during the night.

A. Measuring the patient's height. B. Monitoring the patient's weight gain. C. Reviewing the patient's complete blood count. D. Reviewing the patient's chemistry profile.

Correct Answer is C

Explanation

Reviewing the patient's complete blood count.

Choice A rationale:

Measuring height is not a priority when administering zidovudine.

Choice B rationale:

Monitoring weight gain is important but not the first priority.

Choice C rationale:

Reviewing the complete blood count is crucial before administering zidovudine, as this medication can cause bone marrow suppression. Checking for changes in white blood cell counts, hemoglobin, and platelet levels is essential to ensure the patient can tolerate the medication without severe adverse effects.

Choice D rationale:

Reviewing the patient's chemistry profile is relevant, but assessing blood counts is more critical due to zidovudine's potential impact on bone marrow function.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides a parent with instructions on how to perform the scotch tape test to collect a specimen for ova and parasites in the perineal region of a child suspected of having pinworms. Which action by the parent indicates the test was done at the correct time?

Correct Answer is D

Explanation

When administering zidovudine to a patient with human immunodeficiency virus (HIV), which action should be the first priority for the nurse?

Correct Answer is C

Explanation

A patient has a neurogenic bladder with incomplete emptying. Which discharge instruction for the patient's mother should be included in the teaching plan?

Which statement by the parent of a 10-month-old infant with Down Syndrome indicates the need for further instruction about the child's home care needs?

The nurse is preparing to discharge an 18-month-old patient who has been in the hospital for repair of a cleft palate. Which statement is most appropriate for discharge teaching with the patient's mother?

A 9-year-old patient is admitted to the pediatric unit with a diagnosis of status asthmaticus. Upon entering the hospital room, the nurse observes that the child is sitting and leaning forward on an overbed table. The patient's SpO2 is 93%. The nurse should take which action next?

A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?

Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?

A 4-year-old client is diagnosed with a urinary tract infection. After taking a history about the client from the mother, which data is most likely related to the client's urinary tract infection?

A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?