A five-year-old child with HIV presents with dry cough, shortness of breath, and no weight gain for the past year and is diagnosed with lymphoid interstitial pneumonitis (LIP). The nurse develops the care plan based on the knowledge that:

Choice A reason: This statement is correct, as suctioning the mouth and nasopharyngeal passages is the most important priority for airway care in an infant who has had a cleft palate repair. The nurse should suction the infant frequently and gently to remove any blood, mucus, or secretions that may obstruct the airway or cause aspiration. The nurse should also monitor the infant's respiratory rate, oxygen saturation, and signs of distress.

Choice B reason: This statement is incorrect, as giving IV morphine for pain is not the most important priority for airway care in an infant who has had a cleft palate repair. Although pain management is essential for the infant's comfort and recovery, it is not the first intervention for airway care. The nurse should assess the infant's pain level and administer the prescribed analgesics as needed, but only after ensuring the airway is clear and patent.

Choice C reason: This statement is incorrect, as cleaning the suture line with normal saline is not the most important priority for airway care in an infant who has had a cleft palate repair. Although wound care is important for the prevention of infection and the promotion of healing, it is not the first intervention for airway care. The nurse should clean the suture line with sterile saline or water as ordered, and avoid using cotton swabs or hydrogen peroxide that may damage the tissue or cause bleeding.

Choice D reason: This statement is incorrect, as elevating the head of the bed 30 degrees is not the most important priority for airway care in an infant who has had a cleft palate repair. Although elevating the head of the bed can help reduce the swelling and improve the drainage, it is not the first intervention for airway care. The nurse should position the infant on the side or abdomen, with the head slightly elevated, and avoid placing the infant on the back or putting pressure on the operative site.

Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.

Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.

Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.

Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.