A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?
"Have you tried holding your infant skin-to-skin?"
"is your infant able to latch on during breastfeeding?"
"What is your infant's level of activity?"
"Have you considered joining a parents' support group?"
The Correct Answer is B
A) "Have you tried holding your infant skin-to-skin?":
While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.
B) "Is your infant able to latch on during breastfeeding?":
This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.
C) "What is your infant's level of activity?":
While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.
D) "Have you considered joining a parents' support group?":
Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Verify the medication name along with its intended purpose.
Rationale:
Verifying the medication name along with its intended purpose is crucial to ensure accuracy and patient safety. In this scenario, the nurse should confirm that the medication name "propranolol" matches the intended medication prescribed by the provider. Additionally, understanding the purpose of the medication ensures that the nurse can correctly communicate this information to the patient, reinforcing patient education and adherence to the prescribed treatment plan. Verifying the medication name and purpose helps prevent medication errors and promotes safe medication administration practices.
B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."
Verbalizing the letters "B-I-D" for the dosing frequency instead of saying "twice per day" is not the most appropriate action in this situation. While using medical abbreviations like "B-I-D" (which stands for "bis in die" or "twice a day") is common in healthcare settings, it's essential to ensure clear communication with all involved parties, including patients and providers. Using layman's terms like "twice per day" helps avoid confusion and promotes better understanding, reducing the risk of medication errors due to misinterpretation.
C. Transcribe the medication name using the trade name.
Transcribing the medication name using the trade name is not appropriate unless specifically instructed by the provider or if there is a specific reason to do so. In this scenario, the nurse should use the generic name "propranolol" when transcribing the medication to ensure consistency and accuracy in documentation and communication. Using trade names can lead to confusion, especially in environments where multiple brand names may exist for the same generic medication.
D. Remind the provider to countersign the prescription in 72 hr.
Reminding the provider to countersign the prescription in 72 hours is not relevant to the immediate task of verifying and reading back the prescription information. While ensuring proper documentation and authorization of prescriptions is important, it should not be addressed during the initial verification and communication process. This action can be addressed separately, following the completion of the prescription verification process.
Correct Answer is D
Explanation
Answer: D. Raisin toast
Rationale:
A. Soft-serve ice cream:
While soft-serve ice cream may seem appealing due to its mild taste and smooth texture, it can be high in sugar and fat, which might not be well-tolerated by patients experiencing chemotherapy-induced nausea. Heavy or rich foods can exacerbate nausea, making them less suitable for these clients.
B. Hot tea:
Hot tea can be soothing, but for individuals experiencing nausea, the warmth might not be well-received. Additionally, certain teas can contain caffeine, which may not be advisable for those undergoing chemotherapy, as it can sometimes exacerbate dehydration or jitters.
C. String cheese:
String cheese is a dairy product that can be heavy for some patients, particularly those experiencing nausea from chemotherapy. Dairy may cause gastric discomfort, and many patients may prefer lighter, less greasy options when feeling nauseous.
D. Raisin toast:
Raisin toast is a suitable choice as it is light, easy to digest, and contains carbohydrates that can help settle the stomach. The raisins add some natural sweetness without being overly rich, making it a good option for someone experiencing chemotherapy-induced nausea. This selection demonstrates an understanding of dietary choices that may be better tolerated during episodes of nausea.
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