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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
Correct Answer is D
Explanation
Choice A rationale:
Popcorn can be problematic for a child with Crohn's disease. Crohn's disease is characterized by inflammation in the gastrointestinal tract, and certain high-fiber foods like popcorn can exacerbate symptoms, causing discomfort and potential irritation of the intestinal lining.
Choice B rationale:
Hot dogs are typically high in fat and can be difficult to digest, which can trigger symptoms in a child with Crohn's disease. Additionally, processed meats like hot dogs might contain additives that could worsen inflammation in the digestive tract.
Choice C rationale:
Dried apricots are also not the best choice for a child with Crohn's disease. Dried fruits are concentrated sources of fiber and can be tough on the digestive system, potentially leading to abdominal pain and diarrhea in individuals with inflamed intestines.
Choice D rationale:
Plain yogurt is a suitable food choice for a child with Crohn's disease. It is a good source of protein and calcium and contains probiotics that can promote gut health. Probiotics may help regulate the digestive system and alleviate some symptoms associated with Crohn's disease. However, individual tolerances may vary, so it's important to monitor the child's response to yogurt.
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