A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

Half-strength infant formula

Sterile water

Oral electrolyte solution

Half-strength orange juice

Answer and Explanation

The Correct Answer is C

A. Half-strength infant formula: Infant formula, even if diluted, may not be appropriate immediately after a repair of intussusception. It may be too heavy for the infant's digestive system, potentially leading to complications. Clear fluids are usually preferred initially.

B. Sterile water: Sterile water is not typically recommended for oral intake in infants after a repair of intussusception. It lacks essential electrolytes needed to maintain proper hydration and electrolyte balance.

C. Oral electrolyte solution: Oral electrolyte solutions, such as Pedialyte, are often recommended for infants after a repair of intussusception. These solutions contain balanced electrolytes and fluids, which help prevent dehydration and restore electrolyte balance.

D. Half-strength orange juice: Orange juice, even if diluted, is not typically recommended immediately after a repair of intussusception. It may be too acidic and may cause gastrointestinal discomfort or irritation in the infant. Clear fluids are preferred initially to allow the gastrointestinal tract to rest and recover.

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Correct Answer is C

Explanation

A. Using touch to calm the client during periods of anxiety: Clients with paranoid schizophrenia may have heightened sensitivity to touch and may interpret it as threatening or intrusive. Therefore, using touch to calm the client may exacerbate their anxiety rather than alleviate it.

B. Rotating staff assignments for this client: Consistency in staff assignments can help establish trust and rapport with clients with paranoid schizophrenia. Rotating staff may disrupt this continuity and potentially increase the client's paranoia and suspicion.

C. Checking the client's mouth after the client takes medication: Clients with paranoid schizophrenia may exhibit medication non-compliance due to distrust or suspicion of medications. Checking the client's mouth after medication administration ensures that the client has ingested the medication and helps prevent hoarding or hiding of medication.

D. Assigning assistive personnel to feed the client at mealtimes: Clients with paranoid schizophrenia may have difficulty trusting others, particularly with personal activities such as feeding. Assigning assistive personnel to feed the client may increase the client's paranoia and resistance to care. It's essential to promote the client's autonomy and independence while providing support as needed.

A. Feed the infant with a spoon for 48 hr. B. Apply and release elbow restraints every hour. C. Keep the infant supine D. Suction the mouth with an oral suction tube.

Correct Answer is B

Explanation

A. Feed the infant with a spoon for 48 hr.

Following cleft palate repair, infants may need special feeding techniques to minimize the risk of injury to the surgical site. Feeding with a spoon is a gentle method that reduces the risk of trauma to the repaired palate. However, it is typically recommended for a longer duration than 48 hours, often until the surgical site is fully healed and the healthcare provider provides further instructions. Therefore, this option is not entirely accurate.

B. Apply and release elbow restraints every hour.

Elbow restraints are commonly used postoperatively in infants to prevent them from inadvertently touching or scratching the surgical site. Releasing and reapplying the restraints every hour helps prevent skin breakdown and ensures adequate circulation to the extremities. This intervention helps maintain the integrity of the surgical repair and reduces the risk of complications. Therefore, this is an appropriate intervention for an infant post cleft palate repair.

C. Keep the infant supine

While keeping the infant supine may be necessary to prevent aspiration and promote comfort, it is not the primary intervention to address the surgical repair of the cleft palate. Positioning recommendations may vary based on the surgeon's preferences and the infant's specific needs, but supine positioning alone does not address the prevention of trauma to the surgical site.

D. Suction the mouth with an oral suction tube.

Suctioning the mouth with an oral suction tube may be indicated to maintain airway patency and remove secretions, especially if the infant has difficulty swallowing or clearing oral secretions effectively. However, it is not typically specified as a routine intervention following cleft palate repair unless there are specific concerns about airway compromise or excessive secretions. Therefore, while it may be necessary in some cases, it is not a standard intervention for all infants post cleft palate repair.

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A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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