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 A
Explanation
Lithium toxicity is a significant concern for clients taking lithium, a mood stabilizer commonly prescribed for bipolar disorder. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood, potentially leading to toxicity. Therefore, cautioning against experiencing diarrhea is essential in discharge teaching for clients prescribed lithium.
Option A is correct because it identifies a factor that can contribute to lithium toxicity. Diarrhea can lead to fluid and electrolyte imbalances, affecting lithium levels in the blood.
Option B, drinking green tea, is not typically associated with lithium toxicity. Green tea contains caffeine, but its consumption is not a significant risk factor for lithium toxicity.
Option C, exercising moderately, is generally encouraged for overall health and well-being. However, it does not directly relate to lithium toxicity unless excessive sweating leads to dehydration and electrolyte imbalances.
Option D, increasing sodium intake, is typically discouraged for clients taking lithium because high sodium levels can affect lithium reabsorption in the kidneys, potentially leading to increased lithium levels and toxicity. However, this option is not directly related to the question about factors causing lithium toxicity.
Correct Answer is C
Explanation
A. "I will feed my baby on a schedule every 4 hours": Feeding an infant with heart failure on a strict schedule may not be appropriate because it may not allow the infant to consume adequate calories and nutrients when needed. Infants with heart failure may tire easily during feeding, so they may require more frequent, smaller feedings to ensure adequate intake.
B. "I will add Polycose to each of my baby's bottles": Polycose is a carbohydrate supplement sometimes used to increase the calorie content of infant formula or breast milk. However, adding it to every bottle without guidance from a healthcare provider may not be necessary or appropriate. The decision to use Polycose should be based on the infant's specific nutritional needs and should be directed by the healthcare team.
C. "I will allow my baby to take as much time as needed to finish the bottle": This statement indicates an understanding that infants with heart failure may have difficulty feeding due to fatigue or respiratory distress. Allowing the baby to take as much time as needed to finish the bottle ensures that they can consume an adequate amount of milk without becoming exhausted.
D. "I will limit my baby's crying to 15 minutes prior to each feeding": Limiting the baby's crying before feeding is not directly related to meeting the infant's nutritional needs. While minimizing stress and agitation before feeding can be beneficial, setting a specific time limit on crying may not always be practical or effective.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.