A nurse is caring for an infant who has just returned from the PACU following cleft lip and palate repair. Which of the following actions should the nurse take?
Assess the mouth with a tongue blade.
Remove the packing in the mouth.
Place the infant in an upright position.
Offer a pacifier with sucrose.
The Correct Answer is C
Choice A reason: Assessing the mouth with a tongue blade is not recommended postoperatively as it can cause discomfort and disrupt the surgical site.
Choice B reason: Removing the packing in the mouth is typically done by a healthcare provider, not immediately postoperatively, to avoid bleeding and protect the repair.
Choice C reason: Placing the infant in an upright position is recommended to facilitate breathing and reduce swelling⁷.
Choice D reason: Offering a pacifier with sucrose is not advisable as it can interfere with the healing of the cleft repair⁷.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bed rest is not a specific treatment for Hirschsprung's disease. While rest may be part of preoperative care, it does not address the underlying issue of the disease⁹.
Choice B reason: Surgery is the definitive treatment for Hirschsprung's disease. The pull-through procedure is commonly used to remove the affected section of the colon and connect the healthy part to the anus⁷.
Choice C reason: An NG tube may be used for decompression if there is a bowel obstruction, but it is not a treatment for Hirschsprung's disease itself. Surgery is required to correct the absence of nerve cells in the colon⁹.
Choice D reason: A high-fiber diet is not recommended before surgery as it may increase the risk of enterocolitis and bowel obstruction in patients with Hirschsprung's disease⁹.
Correct Answer is D
Explanation
Choice A reason: Preschool-age children are beginning to understand causality, but they do not fully grasp the cause of illnesses, which often involves complex biological processes.
Choice B reason: While preschoolers are becoming more aware of their bodies, they typically do not have a detailed understanding of body functioning.
Choice C reason: Preschoolers may describe how they feel when they are ill, but they usually cannot accurately describe the manifestations of illnesses.
Choice D reason: Preschoolers often engage in magical thinking, where they believe their thoughts can cause events. This is a normal part of their cognitive development and can include relating fears to magical thinking.
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