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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Constant need to talk about the event. While individuals with PTSD may experience intrusive thoughts or flashbacks related to the traumatic event, a constant need to talk about the event is not universally characteristic. Some individuals with PTSD may avoid discussing the traumatic event altogether due to the distress it causes them, while others may find it helpful to talk about it in therapy or support groups.

B. Increasing feelings of anger. This is the correct choice. Feelings of anger and irritability are common symptoms of PTSD. Individuals may experience heightened levels of anger as a result of feeling violated, powerless, or betrayed by the traumatic event. Anger may be directed toward the perpetrator, oneself, or others, and it can contribute to difficulties in interpersonal relationships and daily functioning.

C. Sleeping 12 hr or more each day. While sleep disturbances are common in PTSD, they typically manifest as insomnia, nightmares, or restless sleep rather than excessive sleep. Individuals with PTSD may struggle to fall asleep, experience frequent awakenings during the night, or have nightmares related to the traumatic event. Excessive sleeping is not typically associated with PTSD.

D. Increasing sense of attachment to others. Individuals with PTSD may experience difficulties in forming or maintaining relationships due to symptoms such as emotional numbing, avoidance of reminders of the trauma, and difficulties in trusting others. While some individuals may seek support from loved ones, an increasing sense of attachment to others is not typically an expected finding in PTSD.

A. Separates easily from primary care giver for short periods of time B. Explains the difference between right and wrong C. Cooperates in doing simple chores D. Prints letters and numbers

Correct Answer is A

Explanation

A. Separates easily from primary caregiver for short periods of time: This is the correct choice. Toddlers typically begin to demonstrate increased independence and are able to separate from their primary caregiver for short periods of time without significant distress. This developmental task reflects the toddler's growing sense of autonomy and confidence in exploring their environment.

B. Explains the difference between right and wrong: While toddlers may begin to understand simple rules and expectations, they are not yet capable of explaining the difference between right and wrong in a comprehensive or abstract manner. Moral development occurs gradually over time and is influenced by various factors, including socialization and parental guidance.

C. Cooperates in doing simple chores: Toddlers may begin to imitate or participate in simple household tasks or routines, but their level of cooperation is typically limited and may vary depending on individual temperament and developmental readiness. While involvement in chores can promote a sense of responsibility and independence, toddlers are still in the early stages of learning basic self-care skills and may require supervision and assistance.

D. Prints letters and numbers: The ability to print letters and numbers typically emerges during the preschool years, around ages 3 to 5, as part of the development of fine motor skills and early literacy. Toddlers are not developmentally ready to master the precision and coordination required for printing letters and numbers. Their focus during the toddler stage is primarily on gross motor skills, sensory exploration, and language development.

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