A nurse is assisting with caring for an infant immediately postoperative following a cleft lip repair. Which of the following actions should the nurse take?
Clean the infant's suture line with chlorhexidine solution.
Apply elbow immobilizers to the infant.
Offer the infant a pacifier with sucrose for pain relief.
Place the infant in a prone position for sleeping.
The Correct Answer is C
Choice A rationale:
Cleaning the infant's suture line with chlorhexidine solution is not indicated immediately after cleft lip repair. The primary concern in the immediate postoperative period is pain management and wound healing, and cleaning the suture line with chlorhexidine could potentially disrupt the healing process.
Choice B rationale:
Applying elbow immobilizers to the infant is not necessary after cleft lip repair. Elbow immobilizers are typically used in situations where there's a need to restrict arm movement, such as preventing a child from bending their arms after certain types of surgery. Cleft lip repair does not involve the arms, so this action is not relevant.
Choice C rationale:
Correct Choice. Offering the infant a pacifier with sucrose for pain relief is appropriate. Non-nutritive sucking, such as using a pacifier, has been shown to have pain-relieving effects in infants. Sucrose, a sweet solution, is often used in combination with non-nutritive sucking to further enhance pain relief during minor procedures or painful experiences. It provides comfort and distraction to the infant, helping to reduce their discomfort.
Choice D rationale:
Placing the infant in a prone position for sleeping is contraindicated after cleft lip repair. Placing an infant prone (on their stomach) for sleep increases the risk of sudden infant death syndrome (SIDS). The recommended sleep position for infants is supine (on their back) to ensure their safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Insulin administration is not appropriate in this situation. The child's symptoms (slurred speech, diaphoresis, low blood glucose reading) indicate hypoglycemia, which is a state of low blood sugar. Administering insulin, which lowers blood glucose further, would exacerbate the hypoglycemia and could lead to more severe symptoms or even unconsciousness.
Choice B rationale:
Metformin is not indicated in this scenario. Metformin is an oral medication used to treat type 2 diabetes, not type 1 diabetes mellitus. The child in the scenario has type 1 diabetes, which is characterized by an absolute deficiency of insulin production.
Choice C rationale:
Offering a 6 oz diet soft drink is not the appropriate intervention for hypoglycemia. Diet soft drinks do not contain significant amounts of sugar, which is needed to rapidly raise the child's blood glucose levels. In cases of hypoglycemia, a source of quickly absorbable sugar, such as a regular soft drink or fruit juice, is recommended.
Choice D rationale:
Administering a 6 oz regular soft drink is the appropriate intervention in this situation. The child is experiencing hypoglycemia, which means their blood glucose levels are dangerously low. Regular soft drinks contain rapidly absorbable sugar that can quickly raise the child's blood glucose levels, alleviating the symptoms of hypoglycemia. The child's symptoms, including slurred speech and diaphoresis, are indicative of a need for immediate intervention to raise blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.