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 B

Explanation

A. Palliative care serves to hasten death and make the process easier for the family is an incorrect statement. Palliative care is focused on providing relief from symptoms and improving the quality of life, not hastening death.

B. Palliative care provides pain and symptom management and best quality of life for the child is the correct understanding of palliative care. It focuses on managing symptoms and providing support to improve quality of life, regardless of the child’s age or stage of illness.

C. The goal of palliative care is to place the child in a hospice setting at the end of life is not entirely correct. Palliative care can be provided at any stage of a serious illness, not just at the end of life, and it does not automatically mean placement in hospice.

D. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals is a supportive role, but it does not fully define the scope of palliative care, which is focused on symptom management and improving quality of life.

A. "My baby's formula can be thickened with oatmeal." B. "I will keep my baby in an upright position after feedings." C. "I will have to feed my baby formula rather than breast milk." D. "I should position my baby side-lying during sleep."

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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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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