A nurse is caring for an infant who is postoperative following repair of a cleft palate. Which of the following is an appropriate action by the nurse?
Gently cleanse the surgical site with sterile gauze.
Place the infant in a supine position.
Apply elbow immobilizers to both arms.
Offer a pacifier with glucose syrup.
The Correct Answer is C
A. Cleansing the surgical site is not typically recommended as it can interfere with healing and cause trauma to the area. The surgical site should be kept clean and dry according to the surgeon's instructions.
B. Placing the infant in a supine position is not recommended as it can increase the risk of aspiration and disrupt the surgical site. Positioning should be done to protect the surgical repair.
C. Applying elbow immobilizers to both arms prevents the infant from touching or putting their hands in their mouth, which helps to protect the surgical site from injury and allows it to heal properly.
D. Offering a pacifier with glucose syrup is not appropriate as sucking on a pacifier can disrupt the surgical site and glucose syrup is not necessary in this situation.
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Related Questions
Correct Answer is D
Explanation
A. Feeding the infant at the first sign of hunger is a general good practice but does not specifically address the increased nutritional needs of an infant with heart failure.
B. A firm nipple may require more effort to suck, which can be tiring for an infant with heart failure. A softer nipple may be more appropriate.
C. Diluting the formula with water can lead to inadequate caloric intake and nutritional deficiencies. Formula should be prepared according to instructions to ensure proper nutrition.
D. Thickening the formula is often recommended to prevent regurgitation and aspiration, which can be particularly dangerous in infants with heart failure due to their compromised cardiac function.
Correct Answer is B
Explanation
A. An increase in potassium levels is not directly related to the effectiveness of furosemide, which is a diuretic and can actually cause hypokalemia.
B. A decrease in edema indicates that the diuretic is effectively removing excess fluid from the body, which is a desired effect of furosemide in treating heart failure.
C. An increase in respiratory rate could indicate worsening heart failure or fluid overload, not the effectiveness of the medication.
D. A decrease in appetite is not a specific indication of the effectiveness of furosemide.
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