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?

Position the infant on its abdomen.

Offer the infant a pacifier.

Encourage the parents to hold and comfort the infant.

Administer Ibuprofen as needed for pain.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is C

Explanation

Choice A rationale

While a period of play in the playroom can be a good distraction and provide a sense of normalcy for a child in a hospital setting, it may not specifically improve cooperation in a child distressed about a new diagnosis of diabetes mellitus.

Choice B rationale

A needleless syringe and a doll can be useful tools for explaining procedures and reducing fear in children. However, they might not directly address the distress caused by a new diagnosis of diabetes.

Choice C rationale

A storybook about a cat who has diabetes can be an effective therapeutic action. It can help the child understand their condition in a non-threatening way, see that they are not alone, and learn how to manage diabetes in daily life. This can improve their cooperation with their new routine of diabetes management.

A. The infant’s intake was adequate. B. The infant’s output was adequate. C. The infant’s lab results were within normal limits. D. The infant’s lab results indicated dehydration.

Correct Answer is D

Explanation

Choice A rationale

Adequate intake is crucial for hydration, but the information provided does not specify the infant’s intake.

Choice B rationale

Adequate output is a good sign of hydration, but the information provided does not specify the infant’s output.

Choice C rationale

Normal lab results could indicate adequate hydration, but the information provided does not specify the infant’s lab results.

Choice D rationale

The infant was admitted with dehydration, and without information on improved intake or output, it is reasonable to conclude that the infant’s lab results indicated dehydration.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a year-old child who has a new diagnosis of diabetes mellitus and is distressed.The nurse recognizes that which of the following therapeutic actions will help improve the child’s cooperation?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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