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. This statement is incorrect because processed foods can contain gluten even if they don't have visible flour. Gluten can be found in many processed foods as an additive or stabilizer, such as in sauces, soups, and processed meats. It's important to always check food labels for gluten ingredients.
B. This is correct. Barley and rye are sources of gluten and must be avoided in a gluten-free diet for those with celiac disease.
C. This is correct. Foods like bread, pasta, and cereal commonly contain gluten and need to be avoided by individuals with celiac disease.
D. This is correct. Using separate serving utensils for gluten-free foods helps prevent cross-contamination, which is critical for managing celiac disease.
Correct Answer is B
Explanation
A. "My baby's formula can be thickened with oatmeal." While some infants with reflux may benefit from thickening their formula, oatmeal is not typically recommended as a thickening agent. Parents should follow specific medical guidance on safe thickening agents for formula.
B. "I will keep my baby in an upright position after feedings." This statement demonstrates an understanding of appropriate management of gastroesophageal reflux (GER). Keeping the baby upright after feeding helps prevent the backflow of stomach contents into the esophagus, reducing reflux symptoms.
C. "I will have to feed my baby formula rather than breast milk." This statement is incorrect. Breast milk is not contraindicated for infants with GER, and in fact, breast milk may be easier to digest and may help reduce reflux symptoms compared to formula.
D. "I should position my baby side-lying during sleep." This statement is not recommended. Babies should be placed on their back for sleep, as side-lying positions can increase the risk of sudden infant death syndrome (SIDS). The back sleep position is safest for all infants, including those with reflux.
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