A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Keep the infant supine.

Suction the mouth with an oral suction tube.

Apply elbow restraints and release them periodically.

Feed the infant with a spoon for 48 hours.

Answer and Explanation

The Correct Answer is C

A. Keep the infant supine is incorrect. After cleft palate repair, it is generally recommended to keep the infant in a position that minimizes pressure on the surgical site. Keeping the infant in a supine position may cause pressure on the repaired area, so side or semi-prone positioning is preferred.

B. Suction the mouth with an oral suction tube is incorrect. Suctioning should be avoided unless absolutely necessary because it can irritate the surgical site and cause trauma to the newly repaired palate.

C. Apply elbow restraints and release them periodically is correct. Elbow restraints are commonly used after cleft palate surgery to prevent the infant from touching or putting pressure on the surgical site. These restraints should be periodically released to allow for movement and prevent skin breakdown.

D. Feed the infant with a spoon for 48 hours is incorrect. After cleft palate repair, feeding should be done carefully. Special feeding bottles or cups are typically used to avoid trauma to the surgical site. Feeding with a spoon may cause pressure on the repair and should be avoided.

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Correct Answer is C

Explanation

A. Gross motor skill development is important for an infant’s overall development, but it is not the primary focus when caring for an infant with a cleft palate. Gross motor skills typically develop at a normal rate unless there are additional concerns.

B. Fine motor skill development is also important, but for an infant with a cleft palate, the primary concern is related to communication and feeding difficulties. Fine motor development generally follows the same trajectory unless there are complicating factors.

C. Speech and language acquisition is the most important area to focus on when planning care for an infant with a cleft palate. A cleft palate can significantly impact the infant’s ability to produce sounds and develop normal speech patterns. Early intervention and support from speech therapists are essential to address these issues.

D. Cognitive development is vital for all infants, but cleft palate primarily affects speech and feeding, making speech and language acquisition the most immediate concern for overall development.

A. Encourage active range of motion exercises B. Administer antibiotics as prescribed C. Apply heat to the affected area D. Administer factor replacement therapy as prescribed

Correct Answer is D

Explanation

A. Encourage active range of motion exercises is incorrect. Active range of motion exercises should be avoided during a bleeding episode, as it may exacerbate the bleeding or cause further injury. Hemophilia requires rest and stabilization during bleeding episodes.

B. Administer antibiotics as prescribed is incorrect. Antibiotics are typically not needed for bleeding episodes unless there is a risk of infection from a wound. The primary concern during a bleeding episode is managing the bleeding, not preventing infection.

C. Apply heat to the affected area is incorrect. Heat is not recommended during a bleeding episode as it can increase blood flow and worsen bleeding. Instead, ice may be applied to help control bleeding and reduce swelling.

D. Administer factor replacement therapy as prescribed is correct. The priority in managing bleeding in a child with hemophilia is to administer factor replacement therapy, which helps to replace the missing clotting factors in the blood, enabling proper clot formation and stopping the bleeding.

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A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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