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 A

Explanation

A)"I don't like it when you address me with that tone of voice.": This is the most therapeutic response. It addresses the inappropriate behavior (the rude tone) in a calm and direct manner, setting a clear boundary while remaining respectful. By focusing on the behavior, the nurse can maintain professionalism and avoid escalating the situation. This response also encourages the client to recognize the impact of their behavior without feeling attacked.

A. "Why are you feeling so down?" B. "I understand. I've felt like that before, too" C. "I’ll just sit here with you for a few minutes then." D. "It might help you feel better if you talk about it"

Correct Answer is C

Explanation

A. "Why are you feeling so down?": This response may come across as intrusive and may not be well-received by the client. It puts pressure on the client to provide an explanation for their feelings, which they may not be ready or willing to do at that moment.

B. "I understand. I've felt like that before, too": While expressing empathy can be helpful, it's important for the nurse to validate the client's current feelings without making assumptions about their own experiences. This response could inadvertently shift the focus away from the client's feelings and onto the nurse's experiences.

C. "I’ll just sit here with you for a few minutes then.": This is the best response as it acknowledges the client's feelings, respects their desire for solitude, and offers the nurse's presence as a source of support without pressure to talk. Simply being present with the client demonstrates empathy and provides comfort during a difficult time.

D. "It might help you feel better if you talk about it": While encouraging the client to talk about their feelings can be beneficial in some situations, it's essential to respect the client's autonomy and readiness to engage in conversation. In this case, the client has expressed a desire not to talk, so offering unsolicited advice to talk may feel dismissive of their feelings.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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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?