A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Encourage attachment.

Minimize crying.

Restrict oral intake.

Initiate range of motion.

Answer and Explanation

The Correct Answer is B

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

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Correct Answer is C

Explanation

Choice A rationale:

Tucking small disposable diapers under the cast edges in the buttock area may cause discomfort to the patient and could also potentially disrupt the cast alignment. It may also not effectively prevent soiling.

Choice B rationale:

Lining the edges of the cast with absorbent pads and securing with tape might not fully protect the cast from urine and feces. The absorbent pads could still allow some leakage and contamination.

Choice C rationale:

Placing a large cloth diaper over the perineal cutout area provides comprehensive protection against urine and feces soiling the cast. This method ensures that the cast remains clean and dry.

Choice D rationale:

Laying the client on a disposable pad with the perineal area exposed to air is not a practical solution. It does not offer adequate protection for the cast, and exposing the perineal area to air could lead to discomfort and potential complications.

A. Prevent contractures of his hips and knees. B. Minimize his cardiac output. C. Minimize his energy expenditure. D. Prevent vomiting.

Correct Answer is C

Explanation

Choice A rationale:

Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.

Choice B rationale:

Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.

Choice C rationale:

Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.

Choice D rationale:

Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.

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A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a plaster hip spica cast. What measure would best protect the cast from being soiled by urine and feces?

Correct Answer is C

Explanation

A nurse is caring for a pediatric patient with congestive heart failure (CHF). What major goal should the nurse include in the care of this patient?

Correct Answer is C

Explanation

An 8-year-old patient with status asthmaticus insists on sitting straight up in bed. Which action should the nurse take?

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