A nurse is caring for a toddler who had a cleft lip and palate repair and is trying to touch the incision site. Which of the following provider prescriptions is recommended for the toddler?
Swaddle the toddler in a blanket.
Place the toddler in bilateral elbow restraints.
Place the child in a mummy restraint.
Obtain a prescription for lorazepam.
The Correct Answer is B
A. Swaddle the toddler in a blanket. While swaddling may be comforting, it does not effectively prevent the toddler from reaching the incision site. Elbow restraints are a more appropriate choice for limiting arm movement and protecting the incision site.
B. Place the toddler in bilateral elbow restraints. Bilateral elbow restraints are commonly used after cleft lip and palate repair to prevent the toddler from touching or disrupting the incision site. These restraints help protect the surgical area while allowing the child to maintain some mobility.
C. Place the child in a mummy restraint. A mummy restraint (wrapping the child tightly) may be too restrictive and can cause distress, as it limits the child's ability to move freely. Elbow restraints are typically a better choice to prevent injury to the surgical site while still allowing some movement.
D. Obtain a prescription for lorazepam. Lorazepam is a sedative and would not be the first-line approach to managing the child's need to prevent touching the incision site. Using physical restraints is a safer and more effective option.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.
Correct Answer is A
Explanation
A. "Lifts head 45° when lying prone." By 2 months of age, infants begin lifting their heads about 45 degrees while on their stomachs, which is an early sign of developing neck and upper body strength.
B. "Rolls over from back to abdomen." Rolling from back to abdomen typically occurs around 6 months of age.
C. "No head lag when pulled into a sitting position." Head lag is still present at 2 months, but it gradually disappears by 4 months as neck muscles strengthen.
D. "Rolls over from abdomen to back." Rolling from abdomen to back typically occurs around 4 months of age, followed by rolling from back to abdomen at about 6 months.
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