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A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply

A.

Position the infant on their back and upright in Semi-Fowler's

B.

Encourage the parents told the baby

C.

Administer aspirin for pain

D.

Apply elbow restraints as ordered

E.

Maintain IV therapy for nutrition

Answer and Explanation

Correct Answer : A,D,E

A. Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and supports respiratory function after surgery.

B. Encouraging parents to hold the baby is important for bonding, but caution should be taken to avoid placing pressure on the surgical site.

C. Aspirin should not be administered due to the risk of Reye's syndrome; acetaminophen is typically used for pain management in infants.

D. Applying elbow restraints as ordered is necessary to prevent the infant from pulling at the surgical site and to ensure proper healing.

E. Maintaining IV therapy is crucial for nutrition until the infant can take oral feeds safely.


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Related Questions

Correct Answer is A

Explanation

A. The primary treatment for congenital aganglionic megacolon (Hirschsprung's disease) is surgical intervention to remove the affected segment of the bowel, allowing for normal bowel function and preventing complications such as bowel obstruction.

B. Oral iron preparations would not address the underlying condition of Hirschsprung's disease, which is related to the lack of nerve cells in the bowel.

C. While counseling may be beneficial for the caregivers regarding the diagnosis and care, it is not the primary treatment for Hirschsprung's disease.

D. While enemas may be used temporarily to relieve constipation, they are not a definitive treatment for the disease, which requires surgical correction.

Correct Answer is C

Explanation

A. Elevating the affected part is correct and helps reduce swelling and bleeding.

B. Resting the affected area is appropriate and will help minimize movement and further bleeding.

C. Applying heat is not recommended for bleeding episodes as it can increase blood flow and exacerbate bleeding; ice is generally recommended.

D. Compressing the site is appropriate as it helps control bleeding and provides pressure to the affected area.

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