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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Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Applying lidocaine and prilocaine cream can help numb the area, reducing pain and discomfort during catheter insertion, which aligns with atraumatic care principles.
Choice B reason: Explaining procedures using familiar objects can help reduce anxiety and fear in children, making the experience less traumatic⁷.
Choice C reason: Allowing the child to make choices can provide a sense of control, which is important for reducing stress during medical procedures⁷.
Choice D reason: Asking parents to leave is not recommended as their presence can be comforting to the child and is part of atraumatic care.
Choice E reason: Performing the procedure in a familiar environment, such as the child's bed, can help minimize stress and fear.
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