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 ["B","C","D"]

Explanation

Choice A rationale

Providing a detailed technical explanation using medical terminology is not an appropriate action when obtaining informed consent for a child. Medical terminology can be complex and difficult for non-medical professionals to understand. Therefore, it is important to explain the information in a way that is easy for the parents and the child (if appropriate) to understand.

Choice B rationale

Ensuring the parents were not pressured to give consent and the consent forms were provided is an appropriate action when obtaining informed consent for a child. It is important that the decision to consent is made freely and without coercion.

Choice C rationale

Explaining the potential adverse effects and benefits is an appropriate action when obtaining informed consent for a child. Parents must be fully informed about the potential risks and benefits of a procedure or treatment to make an informed decision.

Choice D rationale

Providing alternative options for treatment and explaining the possible risks of negative outcomes is an appropriate action when obtaining informed consent for a child. Parents should be aware of all available treatment options and their potential outcomes to make an informed decision.

A. The child is suffering post-traumatic stress. B. The child is fearful of being separated from his/her parents. C. The child is fearful of permanent scarring. D. The child is worried about the pain associated with the procedure.

Correct Answer is D

Explanation

Choice A rationale

Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety. However, a 2-year-old child may not have the cognitive ability to develop PTSD as it requires a certain level of cognitive and psychological development.

Choice B rationale

While separation anxiety is a normal stage of development for infants and toddlers, a 2-year- old child in a burn unit is more likely to be afraid of the pain associated with wound dressing changes rather than being separated from his/her parents.

Choice C rationale

Fear of permanent scarring could be a concern for older children and adults who are more aware of their body image. A 2-year-old child may not have the cognitive ability to understand the concept of permanent scarring.

Choice D rationale

The child is likely worried about the pain associated with the procedure. Pain experienced by patients is likely to increase during procedures such as dressing changes. This is a common and immediate fear for children undergoing medical procedures, especially those associated with pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assisting in obtaining informed consent for a child, which of the following actions were taken? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A 2-year-old child admitted to a burn unit with second and third-degree burns is scheduled for another wound dressing change.The child is anticipating the painful procedure and is anxious and tachycardic as the time approaches. The nurse recognizes that which of the following is likely?

Correct Answer is D

Explanation

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