A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
Keep the infant in a side-lying position.
Remove elbow restraints while the infant is sleeping
Administer pain medication around the clock for the first 72 hr.
Feed the infant half-strength formula for the first 48 hr
Correct Answer : C,D
A. Keep the infant in a side-lying position.
This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.
B. Remove elbow restraints while the infant is sleeping.
Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.
C. Administer pain medication around the clock for the first 72 hours.
This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.
D. Feed the infant half-strength formula for the first 48 hours.
This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer the medication at mealtime.Ferrous sulfate is best absorbed on an empty stomach because food, especially those rich in calcium or tannins, can interfere with its absorption. Administering it with meals reduces its effectiveness.
B.While bedtime administration is not contraindicated, it is not necessary. The timing of administration should focus on maximizing absorption, typically between meals or on an empty stomach.
C. Ferrous sulfate can stain teeth if taken orally in liquid form. Using a straw minimizes contact with teeth, reducing the risk of discoloration. Parents should also be advised to encourage the child to rinse their mouth after taking the medication.
D. Dilute the medication with 240 mL of milk. Milk contains calcium, which inhibits the absorption of iron. Ferrous sulfate should not be taken with milk or dairy products to ensure optimal absorption.
Correct Answer is D
Explanation
A. A 45-degree head elevation: This position can help facilitate venous drainage and reduce intracranial pressure. Elevating the head of the bed may aid in preventing the accumulation of cerebrospinal fluid (CSF) in the brain, which is important after VP shunt insertion to maintain proper drainage. However, this position alone may not be sufficient.
B. On the nonoperative side: Placing the child on the nonoperative side can help reduce pressure on the side where the shunt was inserted, minimizing discomfort and the risk of disruption or displacement of the shunt. However, this position may not directly affect CSF drainage.
C. Prone: Placing the child prone (lying face down) is generally not recommended after VP shunt insertion. This position may increase pressure on the head and interfere with proper CSF drainage, potentially leading to complications.
D. Supine: Placing the child supine (lying on their back) is typically recommended after VP shunt insertion. This position helps promote proper drainage of CSF through the shunt system without placing undue pressure on the surgical site. It also allows for easy monitoring of the child's condition and surgical site.
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