A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Apply and release elbow restraints every hour

Keep the infant supine

Feed the infant with a spoon for 48 hours

Suction the mouth with an oral suction tube

Answer and Explanation

The Correct Answer is A

Choice A reason: Applying and releasing elbow restraints every hour prevents the infant from touching or injuring the surgical site, while allowing some movement and circulation. This is a standard nursing intervention for infants who have undergone cleft palate repair.

Choice B reason: Keeping the infant supine is not recommended, as it increases the risk of aspiration and bleeding. The infant should be placed in a side-lying or upright position to facilitate drainage and prevent pressure on the suture line.

Choice C reason: Feeding the infant with a spoon for 48 hours is not necessary, as it may cause discomfort and trauma to the palate. The infant can be fed with a special nipple or a syringe with a rubber tip that delivers small amounts of formula or breast milk to the side of the mouth.

Choice D reason: Suctioning the mouth with an oral suction tube is contraindicated, as it may damage the palate and cause bleeding or infection. The nurse should use a bulb syringe to gently suction the nose and mouth if needed.

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Correct Answer is A

Explanation

Choice A reason: This is the best option to prevent the toddler from touching or injuring the surgical site. The nurse should apply soft padded restraints and check the circulation and skin integrity of the wrists frequently.

Choice B reason: Offering fluids through a straw is not recommended for a toddler who has had a cleft palate repair, as it can cause suction and pressure in the mouth that can disrupt the sutures. The nurse should offer fluids with a cup or a spoon.

Choice C reason: Implementing a soft diet is not appropriate for a toddler who has had a cleft palate repair, as it can cause irritation and infection in the mouth. The nurse should provide clear liquids for the first 24 hr and then advance to full liquids as tolerated.

Choice D reason: Administering opioids for pain is not the first choice for a toddler who has had a cleft palate repair, as it can cause respiratory depression and constipation. The nurse should use nonpharmacological methods such as distraction, comfort, and reassurance first, and then administer acetaminophen or ibuprofen as prescribed.

A. I'll keep my baby in an upright position after feedings. B. I should position my baby side lying during sleep. C. My baby's formula can be thickened with oatmeal. D. I'll try to feed my baby formula rather than breast milk.

Correct Answer is A

Explanation

Choice A reason: This is the best option to prevent reflux, as it allows gravity to help keep the stomach contents down. The nurse should advise the parent to keep the baby upright for at least 30 minutes after each feeding.

Choice B reason: Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.

Choice C reason: Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.

Choice D reason: Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.

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A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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