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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain IV access. Obtaining IV access is a good precaution in case the client requires emergency medication (e.g., anticonvulsants) to control seizures. This is part of preparing for seizure management.
B. Keep a padded tongue blade available at the client's bedside. This is an outdated practice. The nurse should never insert a tongue blade into a patient's mouth during a seizure as it can cause injury.
C. Keep the lights on when the client is sleeping. There is no need to keep the lights on, as it may disturb the client’s rest. A calm, quiet environment is preferred, and seizure precautions are more related to safety and monitoring than lighting.
D. Place the client's bed in the high position. This increases the risk of injury in the event of a seizure. The bed should be in a low position with side rails up to prevent injury.
Correct Answer is C
Explanation
A. Respiratory rate can be influenced by many factors, including fever or anxiety, and is not the most reliable indicator of fluid loss.
B. Blood pressure may change with severe dehydration, but it can be a late sign, and other factors (like shock) can also affect blood pressure, so it's not the most reliable early indicator.
C. Body weight is the most reliable and sensitive indicator of fluid loss, as even small changes in weight reflect changes in hydration status. Monitoring weight helps assess fluid loss accurately.
D. Skin integrity can be affected by dehydration, but it's not the most reliable indicator of fluid loss. It may take longer to show visible signs such as dry skin or poor turgor.
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