A nurse is caring for a fussy 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Choice A rationale

Positioning the infant on its abdomen after a cleft lip repair is not recommended. This position can put pressure on the surgical site and may lead to complications such as bleeding or infection.

Choice B rationale

Offering a pacifier to an infant who has just undergone a cleft lip repair is not advisable. The sucking motion can cause strain on the surgical site and may lead to complications such as dehiscence (separation of the wound edges) or infection.

Choice C rationale

Encouraging the parents to hold and comfort the infant is the best course of action. Holding provides comfort and security to the infant, which can help in reducing fussiness. Moreover, parental involvement in the care of the infant promotes bonding and has positive effects on the infant’s emotional and psychological well-being.

Choice D rationale

Administering Ibuprofen as needed for pain is not the best option. While Ibuprofen is a good analgesic, it is not the first choice for pain management in infants due to the risk of side effects. Moreover, pain management should be individualized, considering the infant’s age, weight, overall health status, and the nature and extent of the surgery.

Choice A rationale

A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93% is showing signs of severe respiratory distress. The weak cry and pale complexion suggest poor oxygenation and possible hypoxia. Decreased breath sounds and retractions indicate the child is struggling to breathe. An oxygen saturation of 93% is below the normal range for infants, further indicating respiratory distress. This child should be prioritized for treatment.

Choice B rationale

A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress, but not as severe as Choice A12. The ability to speak in full sentences and having a pink complexion suggest that the child is getting

enough oxygen. However, bilateral wheezing indicates some airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for children this age.

Choice C rationale

A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93% is also showing signs of respiratory distress. Speaking in short phrases and sitting upright are signs that the teenager is working harder to breathe. Wheezing indicates airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for teenagers.

Choice D rationale

A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress. Being quiet and pale can indicate poor oxygenation. Bilateral wheezing suggests airway obstruction. An oxygen saturation of 93% is below the normal range for children this age. However, this child’s symptoms are not as severe as those of the 12-month-old in Choice A.