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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Bagels with cream cheese and lox are not recommended as lox may carry a risk of contamination.

B. A vanilla milkshake made with pasteurized milk is safe for a neutropenic diet as pasteurization kills harmful bacteria.

C. Ham and cheese sandwiches may not be safe unless the ham is fully cooked, as deli meats can harbor bacteria.

D. Sushi is not appropriate for a neutropenic diet due to the risk of raw fish and potential bacteria.

A. Administer antibiotics. B. Obtain weight weekly C. Encourage increased fluid intake D. Encourage frequent ambulation

Correct Answer is B

Explanation

A. Antibiotics are not routinely indicated for acute glomerulonephritis unless there is an underlying infection; the condition is often related to an immune response.

B. Monitoring weight is crucial in acute glomerulonephritis to assess for fluid retention and manage edema effectively.

C. Fluid intake may need to be restricted to manage hypertension and edema, so encouraging increased intake is not appropriate.

D. While ambulation is important for general health, it is not a primary intervention for managing acute glomerulonephritis.

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