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.

Answer and Explanation

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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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.

Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.

Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.

Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.

Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.

A. Clubbing of the fingers B. Weak femoral pulses C. Cool skin of lower extremities D. Low blood pressure E. Severe cyanosis

Correct Answer is ["B","C"]

Explanation

Choice A reason: Clubbing of the fingers is not typically associated with coarctation of the aorta; it is more commonly seen in chronic hypoxia conditions.

Choice B reason: Weak femoral pulses are expected in coarctation of the aorta due to the narrowing of the aorta, which can reduce blood flow to the lower extremities.

Choice C reason: Cool skin of the lower extremities can be a result of decreased blood flow due to the narrowed aorta in coarctation.

Choice D reason: High blood pressure is more commonly associated with coarctation of the aorta, especially in the upper body, due to the narrowing of the aorta increasing resistance to blood flow⁷.

Choice E reason: Severe cyanosis can occur in coarctation of the aorta if there is a significant obstruction to blood flow, leading to poor oxygenation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

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