A nurse is caring for an infant in the post-anesthesia care unit following cleft lip and palate repair. What is an appropriate action for the nurse to take?
Offer a pacifier with sucrose for pain relief.
Maintain elbow restraints in the postoperative period.
Place infant in trendelenburg position in the immediate postoperative period.
Provide an ice collar for pain.
The Correct Answer is B
A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.
B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.
C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.
D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fluid intake is usually restricted to prevent fluid overload, which can worsen edema and hypertension in acute glomerulonephritis.
B. Administering antibiotics may be necessary, especially if the condition is secondary to a streptococcal infection, which is a common cause of acute glomerulonephritis.
C. Rest is typically encouraged rather than frequent ambulation, as activity can exacerbate symptoms.
D. Daily weights, not weekly, are crucial for monitoring fluid balance in acute glomerulonephritis.
Correct Answer is ["23"]
Explanation
To calculate the IV fluid rate, first, convert the infant's weight from pounds and ounces to kilograms. There are 2.2 pounds in one kilogram. The infant weighs 16 pounds and 8 ounces, which is 16.5 pounds or approximately 7.5 kilograms when converted (16.5 pounds ÷ 2.2 pounds per kilogram). Next, multiply the infant's weight in kilograms by the prescribed amount of IV fluid, which is 6 mL/kg. This results in 45 mL (7.5 kg × 6 mL/kg). Since the fluid is to be infused over 2 hours, divide the total volume of 45 mL by 2 hours to find the rate per hour. The IV pump should be set to deliver approximately 22.5 mL/hr. After rounding to the nearest whole number, the IV pump should be set to deliver 23 mL/hr.
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