A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply
Position the infant on their back and upright in Semi-Fowler's
Encourage the parents told the baby
Administer aspirin for pain
Apply elbow restraints as ordered
Maintain IV therapy for nutrition
Correct Answer : A,D,E
A. Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and supports respiratory function after surgery.
B. Encouraging parents to hold the baby is important for bonding, but caution should be taken to avoid placing pressure on the surgical site.
C. Aspirin should not be administered due to the risk of Reye's syndrome; acetaminophen is typically used for pain management in infants.
D. Applying elbow restraints as ordered is necessary to prevent the infant from pulling at the surgical site and to ensure proper healing.
E. Maintaining IV therapy is crucial for nutrition until the infant can take oral feeds safely.
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Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and supports respiratory function after surgery.
B. Encouraging parents to hold the baby is important for bonding, but caution should be taken to avoid placing pressure on the surgical site.
C. Aspirin should not be administered due to the risk of Reye's syndrome; acetaminophen is typically used for pain management in infants.
D. Applying elbow restraints as ordered is necessary to prevent the infant from pulling at the surgical site and to ensure proper healing.
E. Maintaining IV therapy is crucial for nutrition until the infant can take oral feeds safely.
Correct Answer is B
Explanation
A. Poor skin turgor typically indicates dehydration, not fluid overload.
B. Shortness of breath can be a sign of fluid overload, particularly in children with renal failure, as excess fluid can accumulate and lead to pulmonary edema.
C. Redness at the tube insertion site may indicate infection but does not specifically relate to fluid overload.
D. Fever is a sign of infection or inflammation and does not directly indicate fluid overload.
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