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 ["A","B","C","E","F"]

Explanation

A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.

B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.

C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.

D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.

E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.

F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.

A. Laxatives B. Thyroid replacement medications C. Diuretics D. Pain medications

Correct Answer is D

Explanation

A. Laxatives are not typically used for sickle cell crisis unless the client is experiencing constipation, which is unrelated to the crisis itself.

B. Thyroid replacement medications are used for hypothyroidism and would not be a first-line treatment for sickle cell crisis.

C. Diuretics may be used in conditions like heart failure or kidney disease, but they are not indicated for sickle cell crisis and may worsen dehydration.

D. Pain medications are the correct intervention during a sickle cell crisis. The crisis involves severe pain due to the sickling of red blood cells blocking blood flow to tissues. Opioids like morphine and hydromorphone are commonly administered to manage the severe pain.

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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

Naxlex Comprehensive Predictor Exams

Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

Correct Answer is D

Explanation

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