When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need?
Prevention of oral infection
Visual stimulation
Nutrition
Prevention of pneumonia
The Correct Answer is C
A. Prevention of oral infection: While oral infection prevention is important, the main concern for a newborn with cleft lip and palate is ensuring proper nutrition. Difficulty with feeding due to the cleft requires immediate intervention to ensure adequate nourishment before surgery.
B. Visual stimulation: Visual stimulation is beneficial for infant development but is not the primary focus in preoperative care for a newborn with a cleft lip and palate. The priority is addressing feeding challenges that affect the baby’s nutritional intake.
C. Nutrition: Infants with cleft lip and palate often struggle with feeding, making proper nutrition the most critical concern. Special feeding techniques are needed to ensure the infant receives enough nourishment before surgery to promote growth and health.
D. Prevention of pneumonia: Although preventing pneumonia is essential, the immediate focus for a newborn with cleft lip and palate is ensuring adequate nutrition. Nutritional support is necessary to maintain overall health and reduce the risk of complications, including pneumonia.
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Related Questions
Correct Answer is D
Explanation
A. Inserting a urinary catheter: Inserting a urinary catheter is an invasive procedure and should be avoided unless absolutely necessary. It carries the risk of infection and discomfort for the infant. Non-invasive methods are preferred for monitoring urine output in most cases.
B. Measuring the amount of water added to formula: Measuring the water added to the formula is helpful for tracking fluid intake, but it does not assess urine output. Accurate urine output assessment requires monitoring what is excreted, not just ingested.
C. Comparing intake and output: While comparing intake and output is important, it may not give an accurate representation of urine output in infants due to the complexities of fluid shifts and retention, particularly when the infant is receiving diuretic therapy. A more precise method is needed to directly measure urine output.
D. Weighing diapers: Weighing diapers is the most accurate and practical method to assess urine output in infants. The weight of a wet diaper can be measured before and after use to calculate the amount of urine excreted. This method is non-invasive and provides a reliable measurement of urine output.
Correct Answer is D
Explanation
A. Notify the health care provider: While notifying the healthcare provider may be necessary if the child's oxygen saturation does not improve, the first step is to assess the child's respiratory status to determine if immediate intervention is needed.
B. Immediately take the child's blood gas: A blood gas may be helpful later, but the priority should be to assess the child's respiratory status and address any immediate concerns with oxygenation before proceeding with more invasive assessments.
C. Give oxygen via face mask at 2 liters per minute: Administering oxygen may be necessary, but the nurse should first assess the child's respiratory status to determine if oxygen supplementation is required and the appropriate delivery method.
D. Assess the child's respiratory status: The most appropriate action is to assess the child's respiratory status. This includes checking for signs of distress, work of breathing, and other factors that could help determine the cause of the low oxygen saturation and guide the appropriate intervention.
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