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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lethargy is a common symptom of hypothyroidism due to decreased metabolism.
B. Hirsutism is not associated with hypothyroidism; it is more commonly seen in conditions like polycystic ovary syndrome (PCOS).
C. Tachycardia is typically associated with hyperthyroidism, not hypothyroidism.
D. Diarrhea is also associated with hyperthyroidism, while hypothyroidism usually causes constipation.
Correct Answer is A
Explanation
A. This statement reassures the child that they are not to blame for the maltreatment and supports their emotional well-being.
B. This statement could make the child feel guilty and is not supportive.
C. The nurse cannot promise confidentiality in cases of suspected abuse, as reporting is mandatory.
D. While this statement is supportive, it does not directly address the child's potential feelings of guilt or self-blame.
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