A nurse is caring for a client during a routine prenatal visit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A reason: Apply Bilateral Wrist Restraints

Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.

Choice B reason: Administer Opioids for Pain

Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.

Choice C reason: Implement a Soft Diet

Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.

Choice D reason: Offer Fluids Through a Straw

Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.

Choice A: Wash raw carrots before cooking

Reason: Washing raw vegetables, including carrots, before cooking is essential to remove dirt, bacteria, and pesticide residues. However, this option is not specific to preventing foodborne illnesses. Washing vegetables is a general hygiene practice, but it does not address the broader aspects of food safety, such as preventing cross-contamination or ensuring proper cooking temperatures. Therefore, while important, it is not the most critical instruction for preventing foodborne illnesses in this context.

Choice B: Separate raw foods from ready-to-eat foods

Reason: Separating raw foods from ready-to-eat foods is crucial to prevent cross-contamination. Raw foods, especially meats, poultry, and seafood, can harbor harmful bacteria that can transfer to ready-to-eat foods if not kept separate. This separation should be maintained during storage, preparation, and cooking. For example, raw meat should be stored on the bottom shelf of the refrigerator to prevent juices from dripping onto other foods. Using separate cutting boards and utensils for raw and ready-to-eat foods further minimizes the risk of cross-contamination.

Choice C: Wash utensils with warm water

Reason: While washing utensils with warm water is a good practice, it is not sufficient on its own to ensure food safety. Utensils that have come into contact with raw meat, poultry, or seafood should be washed with hot, soapy water and sanitized to kill any harmful bacteria. Simply using warm water may not effectively remove or kill bacteria, making this option less critical compared to others that directly address foodborne illness prevention.

Choice D: Practice good hand washing after handling raw eggs, meat, or poultry

Reason: Practicing good hand washing after handling raw eggs, meat, or poultry is one of the most effective ways to prevent foodborne illnesses. Hands can easily transfer bacteria from raw foods to other surfaces, utensils, and foods. Proper hand washing involves scrubbing hands with soap and water for at least 20 seconds, ensuring all parts of the hands are cleaned. This practice helps to eliminate harmful bacteria and reduce the risk of cross-contamination.

Choice E: Ensure all food is cooked to 165°F. Promptly refrigerate foods when finished eating

Reason: Cooking food to the proper internal temperature is essential to kill harmful bacteria that can cause foodborne illnesses. For most foods, an internal temperature of 165°F (73.9°C) is recommended to ensure safety. Using a food thermometer to check the temperature is the best way to ensure food is cooked thoroughly. Additionally, promptly refrigerating foods after eating helps to prevent bacterial growth. Bacteria can multiply rapidly at room temperature, so refrigerating leftovers within two hours (or one hour if the temperature is above 90°F) is crucial for food safety.