A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care?

Encouraging and helping mother to breastfeed

Teaching mother to feed breast milk by gavage

Giving medication to suppress lactation

Providing mother with the appropriate formula for the patient

Answer and Explanation

The Correct Answer is A

Choice A reason: Encouraging and helping mother to breastfeed is a supportive and beneficial nursing intervention for a mother who has given birth to an infant with a cleft palate. Breastfeeding provides optimal nutrition, immunity, and bonding for the infant, and may also help prevent infections and promote healing of the cleft. Breastfeeding may be possible for some infants with cleft palate, especially if the cleft is mild or only affects the soft palate. The nurse should assist the mother with positioning, latching, and using devices such as a nipple shield, a breast pump, or a supplemental nursing system. The nurse should also monitor the infant's weight gain, hydration, and output, and provide emotional support and education to the mother.

Choice B reason: Teaching mother to feed breast milk by gavage is not a necessary or desirable nursing intervention for a mother who has given birth to an infant with a cleft palate. Gavage feeding is a method of providing nutrition through a tube that is inserted through the nose or mouth into the stomach. It is usually used for infants who have severe feeding difficulties or other medical conditions that require tube feeding. However, most infants with cleft palate can be fed orally with proper techniques and equipment, and do not need gavage feeding. Gavage feeding may have complications such as infection, irritation, displacement, or obstruction of the tube. It may also interfere with the infant's oral development and bonding with the mother.

Choice C reason: Giving medication to suppress lactation is not a helpful or respectful nursing intervention for a mother who has given birth to an infant with a cleft palate. Medication to suppress lactation is a drug that inhibits the production of breast milk. It is usually used for mothers who choose not to breastfeed or who have medical contraindications to breastfeeding. However, a cleft palate is not a contraindication to breastfeeding, and the mother may still want to breastfeed or express breast milk for her infant. Giving medication to suppress lactation may cause side effects such as nausea, headache, or depression. It may also deprive the infant of the benefits of breast milk, and the mother of the choice and satisfaction of breastfeeding.

Choice D reason: Providing mother with the appropriate formula for the patient is not a sufficient or comprehensive nursing intervention for a mother who has given birth to an infant with a cleft palate. Formula is an artificial substitute for breast milk that provides nutrition for infants who cannot or do not breastfeed. Formula may be used for infants with cleft palate, especially if breastfeeding is not possible or adequate. However, formula does not provide the same immunity, protection, and bonding as breast milk. Providing formula alone does not address the mother's needs, preferences, or feelings about feeding her infant. The nurse should also offer other options, such as expressing breast milk, using a special bottle or cup, or combining breastfeeding and formula feeding. The nurse should also teach the mother how to prepare, store, and administer the formula safely and hygienically.

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Correct Answer is C

Explanation

Choice A reason: This is not an appropriate intervention. Anger and aggression are not normal behaviors in preschoolers, regardless of their gender. They may indicate underlying emotional or developmental issues that need to be addressed.

Choice B reason: This is not an adequate intervention. Talking to the preschool teacher may provide some information about the child's behavior, but it does not address the root cause or offer any solutions. The nurse should collaborate with the teacher and the parents to develop a plan of care for the child.

Choice C reason: This is the most appropriate intervention. A professional psychosocial assessment can help identify the factors that contribute to the child's anger and aggression, such as family stress, trauma, mental health problems, or learning difficulties. The assessment can also provide recommendations for treatment and support for the child and the family.

Choice D reason: This is not a helpful intervention. Consistent and firm discipline is important for any child, but it may not be enough to change the child's behavior if there are other underlying issues. Moreover, harsh or punitive discipline may worsen the child's anger and aggression. The parent should be encouraged to use positive reinforcement, empathy, and problem-solving skills with the child.

A. Assess the affected extremity for temperature and color. B. Manage hydration with IV fluids until able to tolerate oral fluids. C. Check pulses above the catheterization site for equality and symmetry. D. Monitor vital signs frequently.

Correct Answer is B

Explanation

Choice A reason: This is a correct statement, as assessing the affected extremity for temperature and color can help detect any signs of vascular injury or thrombosis after the cardiac catheterization. The extremity should be warm and pink, indicating adequate blood flow. If the extremity is cold, pale, or cyanotic, it may indicate ischemia or occlusion¹.

Choice B reason: This is not a correct statement, as managing hydration with IV fluids until able to tolerate oral fluids is not a necessary intervention after the cardiac catheterization. The child may be able to resume oral fluids as soon as they are awake and alert, unless there are contraindications such as nausea or vomiting. IV fluids may be given to prevent dehydration or hypotension, but they should be monitored carefully to avoid fluid overload or pulmonary edema¹².

Choice C reason: This is a correct statement, as checking pulses above the catheterization site for equality and symmetry can help detect any signs of arterial injury or spasm after the cardiac catheterization. The pulses should be strong and equal on both sides, indicating normal blood flow. If the pulses are weak, absent, or unequal, it may indicate arterial occlusion or narrowing¹.

Choice D reason: This is a correct statement, as monitoring vital signs frequently can help detect any signs of bleeding, infection, or cardiac complications after the cardiac catheterization. The vital signs should be stable and within normal limits, indicating normal hemodynamic status. If the vital signs are abnormal, such as hypotension, tachycardia, fever, or dysrhythmia, it may indicate hemorrhage, sepsis, or cardiac tamponade¹².

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A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care?

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Naxlex Comprehensive Predictor Exams

A boy aged 4 1/2 years has been having increasingly frequent angry outbursts in preschool. He is aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8-10 weeks. His parents ask the nurse for advice. What is the most appropriate intervention?

Correct Answer is C

Explanation

Nursing interventions for the child after a cardiac catheterization when they first return to the unit include all of the answers below except:

Correct Answer is B

Explanation

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