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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Lethargy is an early sign of increased intracranial pressure (ICP) due to possible shunt malfunction and requires immediate medical attention.

B. Seizure activity can be a late sign of shunt malfunction and is also concerning but lethargy typically appears earlier.

C. Rapid weight gain is less directly related to shunt malfunction and more associated with conditions like hypothyroidism or edema.

D. Disinterest in school could suggest general malaise but is not a specific or early sign of shunt malfunction.

A. Projectile vomiting B. Large amounts of bilious emesis C. Watery diarrhea D. Steatorrhea

Correct Answer is A

Explanation

A. Projectile vomiting is a classic sign of pyloric stenosis, where the thickened pylorus muscle obstructs the passage of food from the stomach to the small intestine, causing forceful vomiting.

B. Large amounts of bilious emesis would suggest an obstruction beyond the pylorus, which is not characteristic of pyloric stenosis.

C. Watery diarrhea is not associated with pyloric stenosis, which typically causes dehydration and constipation.

D. Steatorrhea, or fatty stools, is not a feature of pyloric stenosis but rather is associated with malabsorption syndromes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is reviewing the record of a pediatric client diagnosed with pyloric stenosis. Which assessment finding would the nurse expect to find in the electronic health record?

Correct Answer is A

Explanation

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