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 A
Explanation
Choice A reason: Enuresis can lead to emotional problems such as embarrassment, frustration, and low self-esteem, especially if not managed with sensitivity and support.
Choice B reason: While urinary tract infections can cause enuresis, they are not typically a complication of enuresis itself.
Choice C reason: Urosepsis is a severe infection that can result from a urinary tract infection but is not a common complication of enuresis.
Choice D reason: Progressive kidney disease is not a complication of enuresis. Enuresis is a symptom that can occur in various conditions, including kidney disease, but it does not cause the disease to progress.
Correct Answer is C
Explanation
Choice A reason: Digoxin is used to treat heart conditions by slowing the heart rate and increasing its efficiency. It does not increase the heart rate. The normal heart rate for a 12-month-old infant ranges from 80 to 160 beats per minute.
Choice B reason: If an infant vomits after taking digoxin, repeating the dose could lead to toxicity. Instead, caregivers should wait until the next scheduled dose or contact a healthcare provider for guidance.
Choice C reason: Administering digoxin at regular intervals ensures consistent therapeutic levels in the bloodstream, which is crucial for the medication's efficacy and safety.
Choice D reason: Offering fluids after medication does not interfere with digoxin's absorption. However, caregivers should be aware of the signs of digoxin toxicity, which include vomiting, lethargy, and bradycardia.
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