A nurse is reinforcing teaching with the parents of a 10-week-old infant who is scheduled for surgical repair of a cleft lip. Which of the following pieces of information should the nurse include?
"You should give your baby a pacifier when she cries."
"Your baby will be placed in elbow restraints following surgery."
"Your baby cannot have anything by mouth until 2 hours after surgery."
"You should position your baby on her abdomen following surgery.".
The Correct Answer is B
The correct answer is choice b. “Your baby will be placed in elbow restraints following surgery.”
Choice A rationale:
Giving a pacifier to a baby after cleft lip surgery is generally not recommended as it can put pressure on the surgical site and potentially disrupt the healing process.
Choice B rationale:
Elbow restraints are used to prevent the infant from touching or rubbing the surgical site, which helps in protecting the stitches and ensuring proper healing.
Choice C rationale:
Infants are usually allowed to have fluids by mouth soon after surgery, often within a few hours, to ensure they stay hydrated and to monitor their ability to swallow.
Choice D rationale:
Positioning the baby on their abdomen is not recommended as it can put pressure on the surgical site. Instead, the baby should be positioned on their back or side to avoid any pressure on the repaired lip
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The answer is a. Hard-boiled egg.
Hard-boiled eggs are a safe snack for a toddler.They are soft, easy to chew, and rich in nutrients.
Now, let’s discuss why the other options are not recommended:
b. Grapes: Whole grapes are not recommended for toddlers due to the risk of choking.They are round and slippery, making them difficult for toddlers to chew properly.
c. Raw carrots: Similar to grapes, raw carrots pose a choking hazard for toddlers.They are hard and can break into large pieces that might block a toddler’s airway.
d. Popcorn: Popcorn is not safe for toddlers. The kernels can get stuck in a toddler’s throat and cause choking.Moreover, unpopped or partially popped kernels are hard and can also pose a choking risk.
Correct Answer is B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
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