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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A platelet count of 200,000/mm is within the normal range and does not need to be reported.
Choice B reason: A hematocrit of 40% is also within the normal range for a preschooler and does not require reporting.
Choice C reason: A blood protein level of 5.0 g/dL is low and indicative of nephrotic syndrome, which can lead to serious complications if not addressed.
Choice D reason: A hemoglobin level of 14.5 g/dL is within the normal range and does not need to be reported.
Correct Answer is D
Explanation
Choice A reason:
Bowel sounds are a general indicator of intestinal activity and can be assessed in patients with various conditions. However, they are not specific to the effectiveness of Esomeprazole, which is primarily used to reduce gastric acid production and prevent stress ulcers, particularly in patients with burn injuries⁷.
Choice B reason:
Stool frequency may indicate gastrointestinal motility and function but does not directly assess the effectiveness of Esomeprazole. This drug's main role is to decrease stomach acidity, which would not necessarily change stool frequency unless there was a pre-existing issue related to acid production⁷.
Choice C reason:
Abdominal distention can be caused by a variety of factors, including gas, fluid, or enlargement of organs. While it's important to monitor in burn patients, it does not specifically evaluate the effectiveness of Esomeprazole in preventing gastric acid-related complications⁷.
Choice D reason:
A fecal occult blood test is used to detect bleeding in the gastrointestinal tract, which could signify the development of stress ulcers. Since Esomeprazole is prescribed to prevent such ulcers by reducing stomach acid, this test is a direct measure of the drug's effectiveness in burn patients⁷.
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