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
A: By the age of 7, most children have a grasp of days and dates as part of their routine. However, not being able to verbalize the date does not necessarily indicate a developmental delay, as it could be related to the child's learning environment or educational opportunities.
B: Counting backwards is a skill that develops with age and practice. A 7-year-old may struggle with this task due to various reasons such as lack of practice, but it is not a definitive sign of a developmental delay.
C: Making change involves complex cognitive skills including math, understanding of money value, and transactions, which may still be developing in a 7-year-old. This skill varies widely among children and is influenced by their experiences with money.
D: The ability to distinguish right from left is a developmental milestone typically achieved by the age of 5 to 6 years. Persistent difficulty in telling the difference between right and left at the age of 7 could suggest a developmental delay in spatial awareness.
Correct Answer is B
Explanation
Rationale for A: If the child can describe what frightened them, this would be more consistent with nightmares. Nightmares often involve the ability to recall details of the bad dream, whereas sleep terrors are typically associated with no memory of the event.
Rationale for B: Children with sleep terrors generally do not fully awaken and can usually go back to sleep immediately. This is a key distinction between sleep terrors and nightmares, where the child remains distressed for some time and may be hesitant to fall back asleep.
Rationale for C: Becoming fully awake and in a panic is more characteristic of nightmares, where the child may wake up terrified and struggle to calm down, unlike sleep terrors where they do not fully awaken.
Rationale for D: A child with nightmares is often easily comforted by the presence of a parent. In contrast, children with sleep terrors are difficult to comfort because they are not fully awake and may not respond to soothing efforts.
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