A nurse is assisting with the care of an infant who is postoperative following surgical repair of a cleft lip and palate. Which of the following action should the nurse plan to take?
Gently rub betadine on the infant's incisions to prevent infection.
Place the infant in a prone position for 1 hr to facilitate drainage of secretions.
Weigh the infant once each day using the same scale.
Suction the infant's nose and mouth using an in-line device on the lowest setting.
The Correct Answer is C
Rationale:
A) Rubbing betadine on the infant's incisions is not typically done after surgical repair of a cleft lip and palate, as it can cause irritation and delay wound healing.
B) Placing the infant in a prone position for an extended period is not recommended after cleft lip and palate repair surgery, as it may increase the risk of airway obstruction and compromise wound healing.
C) Weighing the infant daily using the same scale helps monitor for changes in fluid status and overall health status following surgery.
D) Suctioning the infant's nose and mouth may be necessary to maintain airway patency, but it should be done judiciously to avoid trauma to the surgical site.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
Correct Answer is A
Explanation
Rationale:
A) Asking the child to cough deeply can help bring up sputum for sampling.
B) Asking the child to clear their throat might not be effective in obtaining a sputum sample.
C) Using wall suction can be invasive and unnecessary for obtaining a sputum sample.
D) Using a bulb syringe to obtain sputum from the child's mouth might not be effective for obtaining a sputum sample from the lower respiratory tract.
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