A nurse is assisting with caring for an infant immediately postoperative following a cleft lip repair. Which of the following actions should the nurse take?
Clean the infant's suture line with chlorhexidine solution.
Apply elbow immobilizers to the infant.
Offer the infant a pacifier with sucrose for pain relief.
Place the infant in a prone position for sleeping.
The Correct Answer is C
Choice A rationale:
Cleaning the infant's suture line with chlorhexidine solution is not indicated immediately after cleft lip repair. The primary concern in the immediate postoperative period is pain management and wound healing, and cleaning the suture line with chlorhexidine could potentially disrupt the healing process.
Choice B rationale:
Applying elbow immobilizers to the infant is not necessary after cleft lip repair. Elbow immobilizers are typically used in situations where there's a need to restrict arm movement, such as preventing a child from bending their arms after certain types of surgery. Cleft lip repair does not involve the arms, so this action is not relevant.
Choice C rationale:
Correct Choice. Offering the infant a pacifier with sucrose for pain relief is appropriate. Non-nutritive sucking, such as using a pacifier, has been shown to have pain-relieving effects in infants. Sucrose, a sweet solution, is often used in combination with non-nutritive sucking to further enhance pain relief during minor procedures or painful experiences. It provides comfort and distraction to the infant, helping to reduce their discomfort.
Choice D rationale:
Placing the infant in a prone position for sleeping is contraindicated after cleft lip repair. Placing an infant prone (on their stomach) for sleep increases the risk of sudden infant death syndrome (SIDS). The recommended sleep position for infants is supine (on their back) to ensure their safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
Allowing an adolescent driver to answer their phone while driving can lead to distraction, increasing the risk of accidents. Engaging in conversations on the phone diverts the driver's attention from the road, which is unsafe. It's crucial for drivers, especially new ones, to focus solely on driving to prevent accidents.
Choice B rationale:
This choice is correct. Not answering the phone while driving is a responsible behavior that indicates an understanding of the dangers of distracted driving. Parents should encourage their children to focus on the road and avoid distractions like phone calls, promoting safe driving practices.
Choice C rationale:
This statement is incorrect. Adolescents should continue wearing helmets when riding their bikes even after age 13. Wearing helmets helps prevent head injuries in case of accidents. While older adolescents might perceive themselves as less prone to accidents, they are still at risk, and helmets are essential for their safety.
Choice D rationale:
This choice is correct. Wearing appropriate protective clothing, like long pants, while driving an all-terrain vehicle (ATV) is crucial. Long pants can provide some degree of protection against scrapes, scratches, and minor injuries that can occur while operating an ATV. It's a safety measure that shows an understanding of the importance of protective gear.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.
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