A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse Include?

Allow the infant to have soft foods.

Maintain elbow restraints on the infant.

Instruct the parents to feed the infant with a spoon.

Tell the parents to avoid brushing the infant's teeth for two weeks.

Answer and Explanation

The Correct Answer is B

A. Allow the infant to have soft foods: After cleft palate repair, oral intake is typically restricted to prevent trauma to the surgical site. Soft or solid foods can disrupt sutures and increase the risk of bleeding or infection. Oral intake is usually limited to clear liquids or specially prepared feeds until healing is sufficient.

B. Maintain elbow restraints on the infant: Elbow restraints (arm splints) help prevent the infant from touching or putting fingers or objects in the mouth, which could damage the surgical site. This intervention protects the integrity of the repair during the critical postoperative healing period and reduces the risk of complications such as dehiscence or infection.

C. Instruct the parents to feed the infant with a spoon: Spoon feeding can apply pressure to the palate and sutures, potentially causing trauma to the repair site. Feeding is often done using specialized devices such as a syringe, cup, or soft-tipped feeders designed to minimize contact with the surgical area.

D. Tell the parents to avoid brushing the infant's teeth for two weeks: Oral hygiene is still important after cleft palate repair, but brushing must be gentle to avoid trauma. Complete avoidance is unnecessary; instead, the nurse should instruct parents to use soft-bristled brushes and avoid the immediate surgical site while maintaining overall oral cleanliness.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

Maintain an opaque mask over the newborn's eyes when under the lights: Phototherapy can damage the retina due to prolonged light exposure. Properly fitted eye shields protect the eyes while allowing maximum skin exposure to the lights. The mask should be removed during feedings to assess the eyes for irritation or drainage.
Monitor the frequency and consistency of stools: Phototherapy increases bilirubin excretion through stool, often causing loose, greenish stools. Monitoring stool patterns helps evaluate treatment effectiveness and detect dehydration. Increased stool frequency is expected as bilirubin levels decline. Ongoing assessment supports safe fluid balance management.
Apply a mild, fragrance free lotion to exposed skin BID: Lotions and ointments can absorb heat and increase the risk of burns during phototherapy. Topical products may also block light penetration, reducing treatment effectiveness. The skin should remain clean and dry without barriers. Avoiding lotions ensures optimal bilirubin breakdown.
Measure the occipital frontal-circumference (OFC) daily: Daily OFC measurement is indicated for concerns related to hydrocephalus or neurological abnormalities. This newborn’s primary issue is hyperbilirubinemia, not intracranial pathology. Caput succedaneum is already noted and does not require daily OFC monitoring unless head growth abnormalities are suspected.
Offer glucose water supplements between feedings: Supplementing with glucose water can interfere with breastfeeding establishment and does not effectively reduce bilirubin levels. Adequate breast milk intake promotes bilirubin elimination through stool. Water supplementation may contribute to inadequate caloric intake and worsen weight loss
Reposition the newborn every 2 to 3 hr: Frequent repositioning ensures maximum skin exposure to phototherapy lights and prevents pressure injury. Turning the newborn promotes even bilirubin breakdown across body surfaces. It also reduces the risk of skin irritation and supports comfort. Regular repositioning enhances treatment effectiveness.

Correct Answer is ["0.2"]

Explanation

Ordered Dose: 2 mg

Available Concentration: 10 mg/mL

Calculate the volume to administer

Volume to administer = Ordered Dose ÷ Concentration

Volume to administer = 2 ÷ 10

Volume to administer = 0.2 mL

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A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse Include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn. For each potential nursing intervention, click to specify if the action appropriate, nonessential, or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

Correct Answer is ["0.2"]

Explanation

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