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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Placing a toddler in a side-lying position on the affected side after administering otic medication is not recommended. This position can cause the medication to leak out, reducing its effectiveness, and can also increase the risk of infection. It's important to keep the medication in the ear canal for an adequate amount of time to allow it to work properly.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not a critical step for otic medications. While warming certain medications can reduce discomfort, this is not a specific requirement for ear drops. Ensuring the cleanliness of the ear, proper positioning, and correct administration technique are more important.
Choice C rationale:
The correct choice. Sitting the child in an upright position is the recommended approach for administering otic medication. This position helps ensure that the medication remains in the ear canal and is not immediately expelled. It also facilitates better penetration of the medication into the ear canal, increasing its effectiveness.
Choice D rationale:
Gently pulling a child's ear upward is a technique used for administering otic medications to straighten the ear canal and allow better access to the medication. However, this step alone is not sufficient. Proper positioning of the child is equally important to prevent the medication from leaking out.
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.
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