A nurse observes a parent of an infant administer a prescribed oral medication.
Which of the following actions by the parent indicates a need for further instruction?

Inserts medication in the buccal cavity.

Wraps infant in a blanket.

Positions infant in a supine position.

Administers medication with an oral syringe.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Inserting medication in the buccal cavity is an appropriate method for administering oral medication to an infant. The buccal cavity is the area between the cheek and gums, and medication placed here is absorbed directly into the bloodstream.

Choice B rationale

Wrapping the infant in a blanket can provide comfort and security during medication administration, making it easier for both the parent and the infant.

Choice C rationale

Positioning the infant in a supine position during oral medication administration is not safe. This position increases the risk of aspiration, which can lead to choking.

Choice D rationale

Administering medication with an oral syringe is an appropriate method for giving oral medication to an infant. It allows for accurate dosing and can be directed towards the cheek to prevent choking.

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Correct Answer is C

Explanation

Choice A rationale

While providing age-appropriate stimulation is important for a newborn’s development, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.

Choice B rationale

Promoting maternal-infant bonding is important, but it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.

Choice C rationale

Maintaining the integrity of the sac is the priority nursing goal for a newborn with a myelomeningocele. The sac contains exposed neural tissue that is at risk for injury and infection. Protecting the sac from damage and keeping it clean and moist until surgery can help prevent complications.

Choice D rationale

While educating the parents about the defect is an important part of nursing care, it is not the priority nursing goal for a newborn with a myelomeningocele. The immediate focus should be on preventing infection and injury to the exposed neural tissue.

A. Remove elbow restraints while the infant is sleeping. B. Keep the infant in a side-lying position. C. Feed the infant half-strength formula for the first 48 hr. D. Administer pain medication PRN for the first 48 hr. .

Correct Answer is D

Explanation

Choice A rationale

Removing elbow restraints while the infant is sleeping is not a recommended intervention following cleft palate repair. Elbow restraints are used to prevent the infant from touching the surgical site and potentially causing injury or infection. Therefore, they should not be removed while the infant is sleeping.

Choice B rationale

Keeping the infant in a side-lying position is not a specific recommended intervention following cleft palate repair. The position of the infant following surgery will depend on various factors, including the infant’s comfort and the surgeon’s instructions.

Choice C rationale

Feeding the infant half-strength formula for the first 48 hours is not a specific recommended intervention following cleft palate repair. The infant’s feeding regimen following surgery will depend on various factors, including the infant’s age, weight, and overall health, as well as the surgeon’s instructions.

Choice D rationale

Administering pain medication PRN (as needed) for the first 48 hours is a recommended intervention following cleft palate repair. Pain management is an important part of postoperative care, and appropriate pain medication can help ensure the infant’s comfort and promote healing.

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A nurse observes a parent of an infant administer a prescribed oral medication.Which of the following actions by the parent indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery.Which of the following nursing goals is the priority in the care of this infant?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair.Which of the following interventions should the nurse contribute to the client’s plan of care?

Correct Answer is D

Explanation

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A nurse observes a parent of an infant administer a prescribed oral medication.
Which of the following actions by the parent indicates a need for further instruction?