A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Encourage the parents to rock the infant.
Administer ibuprofen as needed for pain.
Position the infant on her abdomen.
Offer the infant a pacifier
The Correct Answer is A
Correct answer: A
A. Encourage the parents to rock the infant: Rocking provides comfort and soothing for the infant. It helps reduce anxiety and promotes relaxation during the immediate postoperative period
B. Administer ibuprofen as needed for pain: Administering ibuprofen as needed for pain is not typically recommended for infants under 6 months of age without specific instructions from the healthcare provider. Ibuprofen is generally avoided in young infants due to potential risks of adverse effects, especially in the immediate postoperative period
C. Position the infant on her abdomen: After cleft lip repair surgery, it is generally recommended to position the infant on her back to prevent any pressure on the surgical site and to minimize the risk of infection. Placing the infant on her abdomen may interfere with the healing process and increase the risk of complications.
D. Offer the infant a pacifier.
Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.
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Correct Answer is B
Explanation
In this scenario, the infant has a heart rate of 190/min and a fever of 40°C (104°F). Fever in infants can cause an increase in heart rate, which is a normal physiological response to elevated body temperature. Fever is the body's way of responding to an infection or illness, and it triggers various physiological changes, including an increase in heart rate. This helps the body to circulate blood and deliver immune cells to fight off the infection.
The other options are not accurate or relevant to the infant's current condition:
A. "This is within the expected range for your baby." - A heart rate of 190/min is above the normal expected range for a 2-month-old infant, which is typically between 120 to 160 beats per minute. This response would not address the elevated heart rate and fever.
C. "As your baby begins to fall asleep, his heart rate will decrease." - While heart rate may decrease during sleep, it does not explain the elevated heart rate and fever observed in this situation.
D. "Your baby's heart is beating fast in an attempt to cool down his body." - While tachycardia (fast heart rate) can be associated with increased metabolic demands during fever, the main reason for the increased heart rate in this case is the fever itself, not the body's attempt to cool down. Fever is a response to infection or illness and can cause an increase in heart rate as part of the body's normal immune response.
Correct Answer is D
Explanation
For a 6-month-old infant who has undergone the repair of an intussusception, the nurse should select an oral electrolyte solution. This solution is specifically designed to replace lost fluids and electrolytes due to vomiting or diarrhea, which is crucial in preventing dehydration in infants.
Options A, B, and C are not suitable choices for an infant in this situation:
A. Half-strength orange juice: Citrus juices, including orange juice, are not recommended for infants under 12 months old. They are acidic and may cause stomach upset or diarrhea.
B. Sterile water: Sterile water does not contain the necessary electrolytes, and offering plain water to an infant after surgery or during an illness can lead to electrolyte imbalances and further dehydration.
C. Half-strength infant formula: Diluting infant formula can lead to inadequate nutrition for the infant. The baby requires appropriate nutrition to support recovery after surgery, and diluting formula can be harmful.
D. An oral electrolyte solution is the best choice as it helps maintain proper hydration and electrolyte balance in the infant's body during the recovery period. If the infant tolerates the oral electrolyte solution well and is not at risk for aspiration, the healthcare provider may gradually advance the diet to include other clear liquids and then slowly reintroduce regular infant formula or breast milk as appropriate. The healthcare provider's instructions should be followed carefully to support the infant's recovery and ensure adequate nutrition.
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