A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. Which of the following actions should the nurse take?

A. Encourage the parents to remain in the room: Adolescents benefit from privacy during a physical examination to promote trust, autonomy, and open communication about sensitive issues. Parents may be asked to step out during parts of the exam, so keeping them present at all times is not recommended.

B. Avoid using medical terminology during the examination: While explanations should be clear, avoiding all medical terminology can limit the adolescent’s understanding. Using age-appropriate language along with brief medical terms helps the adolescent learn about their health and fosters health literacy.

C. Allow the adolescent to handle the equipment: Allowing the adolescent to interact with examination tools (e.g., stethoscope, blood pressure cuff) reduces anxiety, promotes engagement, and increases cooperation. Hands-on involvement empowers the adolescent and helps them feel more comfortable during the assessment.

D. Limit the adolescent's choices throughout the examination: Providing choices whenever possible, such as the order of nonurgent assessments or clothing options, supports autonomy and collaboration. Restricting choices can increase resistance and reduce the adolescent’s comfort.

A. Allow the infant to have soft foods: After cleft palate repair, oral intake is typically restricted to prevent trauma to the surgical site. Soft or solid foods can disrupt sutures and increase the risk of bleeding or infection. Oral intake is usually limited to clear liquids or specially prepared feeds until healing is sufficient.

B. Maintain elbow restraints on the infant: Elbow restraints (arm splints) help prevent the infant from touching or putting fingers or objects in the mouth, which could damage the surgical site. This intervention protects the integrity of the repair during the critical postoperative healing period and reduces the risk of complications such as dehiscence or infection.

C. Instruct the parents to feed the infant with a spoon: Spoon feeding can apply pressure to the palate and sutures, potentially causing trauma to the repair site. Feeding is often done using specialized devices such as a syringe, cup, or soft-tipped feeders designed to minimize contact with the surgical area.

D. Tell the parents to avoid brushing the infant's teeth for two weeks: Oral hygiene is still important after cleft palate repair, but brushing must be gentle to avoid trauma. Complete avoidance is unnecessary; instead, the nurse should instruct parents to use soft-bristled brushes and avoid the immediate surgical site while maintaining overall oral cleanliness.