A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Keep the infant supine.

Suction the mouth with an oral suction tube.

Apply elbow restraints and release them periodically.

Feed the infant with a spoon for 48 hours.

Answer and Explanation

The Correct Answer is C

A. Keep the infant supine is incorrect. After cleft palate repair, it is generally recommended to keep the infant in a position that minimizes pressure on the surgical site. Keeping the infant in a supine position may cause pressure on the repaired area, so side or semi-prone positioning is preferred.

B. Suction the mouth with an oral suction tube is incorrect. Suctioning should be avoided unless absolutely necessary because it can irritate the surgical site and cause trauma to the newly repaired palate.

C. Apply elbow restraints and release them periodically is correct. Elbow restraints are commonly used after cleft palate surgery to prevent the infant from touching or putting pressure on the surgical site. These restraints should be periodically released to allow for movement and prevent skin breakdown.

D. Feed the infant with a spoon for 48 hours is incorrect. After cleft palate repair, feeding should be done carefully. Special feeding bottles or cups are typically used to avoid trauma to the surgical site. Feeding with a spoon may cause pressure on the repair and should be avoided.

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Correct Answer is C

Explanation

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin is incorrect. An inguinal hernia involves a protrusion of bowel or fatty tissue through a weakness in the abdominal wall, not digestive fluids leaking from the bowel.

B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin is incorrect. Inguinal hernias are congenital or result from increased intra-abdominal pressure, not caused by viral infections.

C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin is correct. Inguinal hernias occur when tissue, usually part of the intestine or fatty tissue, pushes through a weak area in the abdominal wall near the groin. This condition is common in infants and children.

D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin is incorrect. While excess gas can cause bloating or discomfort, it is not responsible for the development of an inguinal hernia. The bulge is caused by the protrusion of tissue through a weakness in the abdominal wall.

A. Administer antipyretic therapy B. Place the child in a lateral Sims position C. Place the child on droplet precautions D. Reduce all environmental stimuli

Correct Answer is C

Explanation

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.

B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.

C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.

D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.

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A nurse is caring for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Nursing Test Bank

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Explanation

Correct Answer is C

Explanation

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