A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?
Feed the infant with a spoon for 48 hr.
Apply and release elbow restraints every hour.
Keep the infant supine
Suction the mouth with an oral suction tube.
The Correct Answer is B
A. Feed the infant with a spoon for 48 hr.
Following cleft palate repair, infants may need special feeding techniques to minimize the risk of injury to the surgical site. Feeding with a spoon is a gentle method that reduces the risk of trauma to the repaired palate. However, it is typically recommended for a longer duration than 48 hours, often until the surgical site is fully healed and the healthcare provider provides further instructions. Therefore, this option is not entirely accurate.
B. Apply and release elbow restraints every hour.
Elbow restraints are commonly used postoperatively in infants to prevent them from inadvertently touching or scratching the surgical site. Releasing and reapplying the restraints every hour helps prevent skin breakdown and ensures adequate circulation to the extremities. This intervention helps maintain the integrity of the surgical repair and reduces the risk of complications. Therefore, this is an appropriate intervention for an infant post cleft palate repair.
C. Keep the infant supine
While keeping the infant supine may be necessary to prevent aspiration and promote comfort, it is not the primary intervention to address the surgical repair of the cleft palate. Positioning recommendations may vary based on the surgeon's preferences and the infant's specific needs, but supine positioning alone does not address the prevention of trauma to the surgical site.
D. Suction the mouth with an oral suction tube.
Suctioning the mouth with an oral suction tube may be indicated to maintain airway patency and remove secretions, especially if the infant has difficulty swallowing or clearing oral secretions effectively. However, it is not typically specified as a routine intervention following cleft palate repair unless there are specific concerns about airway compromise or excessive secretions. Therefore, while it may be necessary in some cases, it is not a standard intervention for all infants post cleft palate repair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Unaware of compulsions: Clients with obsessive-compulsive disorder (OCD) are usually aware of their compulsions, which are repetitive behaviors or mental acts performed in response to obsessions. Compulsions are typically recognized by the individual as excessive or unreasonable, although they feel driven to perform them.
B. Irrational fear of certain objects: While individuals with OCD may experience irrational fears or obsessions, these are not exclusive to the disorder. Phobias, generalized anxiety disorder, and other conditions can also involve irrational fears of specific objects or situations. OCD is characterized more by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) rather than specific fears.
C. Perfectionist behavior: Perfectionism is a common characteristic of OCD. Individuals with OCD often feel a strong need for things to be perfect or "just right." They may spend excessive amounts of time on tasks to ensure perfection or may be overly concerned with order, symmetry, or cleanliness.
D. Difficulty relaxing: Individuals with OCD often experience significant anxiety related to their obsessions and compulsions. This can make it difficult for them to relax or feel at ease, as their symptoms may constantly occupy their thoughts and compel them to engage in repetitive behaviors.
E. Rule conscious behavior: People with OCD often exhibit rule-bound or rule-conscious behavior. They may adhere rigidly to specific routines, rituals, or rules in an attempt to alleviate anxiety or prevent perceived negative consequences associated with their obsessions. This behavior can manifest as strict adherence to self-imposed rules or rituals, even when these behaviors are not logically connected to the obsession.
Correct Answer is B
Explanation
A. A semi-private room with a roommate who has a similar diagnosis. Placing a client experiencing a manic episode in a semi-private room with another client who also has a similar diagnosis could potentially exacerbate symptoms or lead to conflict. Manic clients may have increased energy levels, impulsivity, and decreased need for sleep, which could disrupt the roommate's rest and compromise their safety.
B. A private room close to the nursing station. Assigning a private room close to the nursing station is the most appropriate option for a client in the manic phase of bipolar disorder. This allows for closer monitoring and supervision by nursing staff, as well as easier access for interventions and assistance when needed. It also helps to minimize stimulation and provide a more controlled environment for the client.
C. A private room in a quiet location on the unit. While a quiet location may be beneficial for some clients, a private room close to the nursing station offers better access to supervision and support from staff, which is particularly important for clients experiencing mania. Additionally, a quiet location may not always be feasible in a busy psychiatric unit.
D. A seclusion room until the client's activity level becomes more subdued. Using a seclusion room should only be considered as a last resort and when absolutely necessary to ensure the safety of the client and others. It should not be the first choice for a client in the manic phase of bipolar disorder. Placing the client in seclusion may further escalate agitation and increase feelings of isolation and distress.
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