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 D

Explanation

The correct answer is: D

Choice A reason:

Placing an infant on their left side after feeding is not the most recommended position for managing gastroesophageal reflux (GER). While it may be better than lying flat on the back, it does not provide the same benefits as keeping the infant in an upright position.

Choice B reason:

Positioning an infant on their right side is generally not advised for GER management. This position can potentially worsen reflux as it may facilitate the backflow of stomach contents into the esophagus due to the stomach's anatomical orientation.

Choice C reason:

Placing an infant in a prone position, especially after feeding, is strongly discouraged due to the increased risk of sudden infant death syndrome (SIDS). Although this position may reduce gastroesophageal reflux, the potential risks far outweigh the benefits.

Choice D reason:

Placing an infant in an infant seat is the recommended position following feedings for a child with GER. This position helps keep the infant upright, allowing gravity to aid in keeping the stomach contents from coming back up into the esophagus. However, it's important to note that the infant seat should not be inclined, as semi-supine positioning can exacerbate GER.

A. "We will restrict the amount of salt in our child's food." B. "I'll limit my child's fluid intake." C. "We will give our child pancreatic enzymes with snacks and meals." D. "We'll prepare low-fat meals with limited protein for my child."

Correct Answer is C

Explanation

Choice A reason: Restricting salt in a child with CF is not advised because these children can lose excessive amounts of salt when they sweat. Maintaining adequate salt intake is important to prevent electrolyte imbalances.

Choice B reason: Limiting fluid intake is not recommended for children with CF. Adequate hydration helps to thin mucus secretions, making them easier to clear from the lungs.

Choice C reason:This is the correct choice. Pancreatic enzyme replacement therapy is essential for children with CF because it helps them digest and absorb nutrients from their food, which is critical due to the malabsorption issues associated with CF.

Choice D reason: Preparing low-fat meals with limited protein is not recommended for children with CF. They require a high-calorie diet with sufficient protein to meet their nutritional needs due to their increased metabolic rate and malabsorption issues.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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