The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this infant’s postoperative care should be included?
Cleansing the suture line, upright position, arm restraints
Mouth irrigations, prone position, cleansing the suture line
Frequent oral suction, spoon feed, give them a teething toy
Arm restraints, postural drainage, mouth irrigations
The Correct Answer is A
Choice A reason:
Cleansing the suture line, maintaining an upright position, and using arm restraints are crucial aspects of postoperative care for an infant after cleft lip repair. Cleansing the suture line helps prevent infection and promotes healing. Keeping the infant in an upright position reduces the risk of aspiration and helps with breathing. Arm restraints prevent the infant from touching or rubbing the surgical site, which could disrupt the healing process.
Choice B Reason:
Mouth irrigations and a prone position are not recommended for postoperative care after cleft lip repair. Mouth irrigations can be too harsh for the delicate surgical site, and a prone position (lying face down) can increase the risk of aspiration and breathing difficulties. Cleansing the suture line is important, but the other aspects of this choice are not suitable.
Choice C Reason:
Frequent oral suction and spoon feeding are not appropriate for an infant after cleft lip repair. Oral suction can be too aggressive and may damage the surgical site. Spoon feeding is not recommended as it can put pressure on the healing lip. Giving a teething toy is also not advisable as it can cause the infant to put objects in their mouth, potentially harming the surgical site.
Choice D Reason:
Arm restraints are indeed necessary to prevent the infant from touching the surgical site. However, postural drainage and mouth irrigations are not suitable for postoperative care after cleft lip repair. Postural drainage is not relevant to this condition, and mouth irrigations can be too harsh for the healing tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answers are a) Use a straw to administer the medication, b) Give the medication with vitamin C, and c) It is best to give the medication with food.
Choice A reason:
Using a straw to administer ferrous sulfate is recommended to prevent staining of the teeth. Ferrous sulfate, especially in liquid form, can cause discoloration of the teeth if it comes into direct contact with them. By using a straw, the medication bypasses the teeth, reducing the risk of staining.
Choice B reason:
Giving ferrous sulfate with vitamin C is beneficial because vitamin C enhances the absorption of iron. Vitamin C (ascorbic acid) helps convert iron into a form that is more easily absorbed by the body. Therefore, administering ferrous sulfate with a source of vitamin C, such as orange juice, can improve its effectiveness.
Choice C reason:
It is best to give ferrous sulfate with food to reduce gastrointestinal side effects. While iron is best absorbed on an empty stomach, it can cause stomach upset, nausea, and constipation. Taking the medication with food can help mitigate these side effects, making it more tolerable for the child.
Choice D reason:
Giving ferrous sulfate with milk is not recommended. Dairy products, including milk, can interfere with the absorption of iron. Calcium in milk binds with iron, reducing its bioavailability and effectiveness. Therefore, it is best to avoid giving ferrous sulfate with milk or other dairy products.
Correct Answer is B
Explanation
Choice A reason:
Removing the harness several times a day is not recommended. The Pavlik harness should be worn continuously as prescribed by the doctor to ensure proper hip development. Removing it frequently can disrupt the treatment and may lead to complications.
Choice B Reason:
Placing a superabsorbent disposable diaper over the harness is important to keep the harness clean and dry. This helps prevent skin irritation and maintains hygiene. It is essential to ensure that the diaper is properly positioned to avoid any interference with the harness.
Choice C Reason:
Returning to the clinic every 12 weeks for adjustment of the harness is not accurate. Typically, follow-up visits are more frequent, especially in the initial stages of treatment. Regular adjustments are necessary to ensure the harness is fitting correctly and effectively promoting hip development.
Choice D Reason:
Applying lotion or powder to minimize skin irritation is not recommended. Lotions and powders can accumulate and cause further irritation or infection. Instead, keeping the skin clean and dry is the best way to prevent irritation while using the Pavlik harness.
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