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) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.

B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.

C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.

D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.

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Correct Answer is B

Explanation

A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.

D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.

A. Decreased blood pressure B. Pale yellow urine C. Periorbital edema D. Increased urination

Correct Answer is C

Explanation

A. Decreased blood pressure is not typically associated with acute glomerulonephritis. In fact, hypertension is a common finding in this condition.
B. Pale yellow urine is a nonspecific finding and is not typically associated with acute glomerulonephritis.
C. Periorbital edema, which is swelling around the eyes, is a classic manifestation of acute glomerulonephritis due to fluid retention and is caused by impaired kidney function.
D. Increased urination is not a typical finding in acute glomerulonephritis. Instead, oliguria or decreased urine output is more common due to decreased glomerular filtration rate.

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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 establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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