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
Position the infant on their back and upright in Semi-Fowler's
Encourage the parents told the baby
Administer aspirin for pain
Apply elbow restraints as ordered
Maintain IV therapy for nutrition
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. Administering Benadryl may help with allergic reactions but is not the immediate priority when the patient is showing signs of severe hypotension and respiratory distress.
B. Applying ice to the site may help with local swelling but does not address the systemic reaction the child is experiencing.
C. Giving epinephrine is the priority action as it counteracts the anaphylactic reaction, improves blood pressure, and alleviates respiratory distress.
D. Determining if the sting is in situ is less critical than addressing the child's life-threatening symptoms.
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