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","B","D"]
Explanation
A. Covering the scale with a clean sheet of paper is unnecessary and does not affect the accuracy of the weight or length measurement.
B. Measuring the infant's length from the crown of the head to the heels of the feet is the correct method for obtaining length measurements in infants.
C. Placing a stadiometer on the top of the infant's head is incorrect; the measurement should be taken from head to heel.
D. Ensuring the scale is balanced to "0" before weighing the infant is essential for obtaining an accurate weight measurement.
E. Obtaining the infant's weight with their diaper on may add unnecessary weight, potentially affecting the accuracy of the weight measurement.
Correct Answer is D
Explanation
A. Tinnitus is not commonly associated with hypocalcemia. It is more often related to issues with the auditory system or certain medications.
B. Elevated blood pressure is not a typical sign of hypocalcemia. Hypocalcemia usually affects neuromuscular function rather than causing changes in blood pressure.
C. Constipation is not commonly linked to hypocalcemia. More frequent symptoms include neuromuscular irritability and spasms.
D. Muscle tremors are a common finding in hypocalcemia due to increased neuromuscular excitability. Hypocalcemia can lead to symptoms such as muscle cramps, spasms, and tremors due to the low levels of calcium affecting nerve and muscle function.
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