A nurse is assisting with the care of an infant who is postoperative following surgical repair of a cleft lip and palate. Which of the following action should the nurse plan to take?
Gently rub betadine on the infant's incisions to prevent infection.
Place the infant in a prone position for 1 hr to facilitate drainage of secretions.
Weigh the infant once each day using the same scale.
Suction the infant's nose and mouth using an in-line device on the lowest setting.
The Correct Answer is C
Rationale:
A) Rubbing betadine on the infant's incisions is not typically done after surgical repair of a cleft lip and palate, as it can cause irritation and delay wound healing.
B) Placing the infant in a prone position for an extended period is not recommended after cleft lip and palate repair surgery, as it may increase the risk of airway obstruction and compromise wound healing.
C) Weighing the infant daily using the same scale helps monitor for changes in fluid status and overall health status following surgery.
D) Suctioning the infant's nose and mouth may be necessary to maintain airway patency, but it should be done judiciously to avoid trauma to the surgical site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Weight loss is not typically expected in heart failure; fluid retention and weight gain are more common.
B) A heart rate of 65/min may be within the normal range for a toddler and does not specifically indicate heart failure.
C) Bounding peripheral pulses are not typically associated with heart failure; weak pulses may be more indicative.
D) Decreased urine output can occur in heart failure due to reduced cardiac output and poor renal perfusion.
Correct Answer is C
Explanation
Rationale:
A) It's important to burp a baby mid-feed and after the feed to prevent discomfort, especially for a baby with a cleft lip.
B) Using a wide-based nipple may be more appropriate for a baby with a cleft lip to help with proper latch and feeding.
C) Holding the baby in an upright position during feedings can help prevent milk from entering the nasal passages, which is important for babies with cleft lip.
D) Encouraging the baby to maintain relaxed cheeks during feeding may not be applicable for a baby with a cleft lip, as proper positioning and latch are more critical.
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