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.
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Related Questions
Correct Answer is D
Explanation
A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.
B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.
C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.
D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.
Correct Answer is D
Explanation
A. While monitoring blood pressure is important, a blood pressure of 98/62 mm Hg may not immediately warrant notification unless there are signs of hypotension or other symptoms. The focus should be on careful management of fluid and electrolytes.
B. In cases of acute renal failure, potassium levels can become elevated due to impaired renal function. Therefore, IV fluids should typically be low in potassium to prevent hyperkalemia.
C. In acute renal failure, a diet high in protein and sodium is not recommended. Instead, dietary restrictions are usually advised to manage waste products and fluid balance.
D. Administering IV fluids slowly helps to prevent fluid overload, which is crucial in managing renal failure and maintaining hemodynamic stability.
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