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 ["C","D"]
Explanation
A. Frequent, thorough handwashing is essential to prevent infection, especially for immunocompromised children.
B. Having the child sleep in a separate bed and room may help minimize exposure to pathogens from family members.
C. Encouraging frequent close contact with visitors increases the risk of infections and should be avoided.
D. Fresh flowers and plants can harbor bacteria and should be avoided in the environment of an immunocompromised child.
E. Protecting the central venous access device is vital to prevent infections; this practice should be emphasized.
Correct Answer is A
Explanation
A. The primary treatment for congenital aganglionic megacolon (Hirschsprung's disease) is surgical intervention to remove the affected segment of the bowel, allowing for normal bowel function and preventing complications such as bowel obstruction.
B. Oral iron preparations would not address the underlying condition of Hirschsprung's disease, which is related to the lack of nerve cells in the bowel.
C. While counseling may be beneficial for the caregivers regarding the diagnosis and care, it is not the primary treatment for Hirschsprung's disease.
D. While enemas may be used temporarily to relieve constipation, they are not a definitive treatment for the disease, which requires surgical correction.
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