A nurse is caring for an infant in the post-anesthesia care unit following cleft lip and palate repair. What is an appropriate action for the nurse to take?
Offer a pacifier with sucrose for pain relief.
Maintain elbow restraints in the postoperative period.
Place infant in trendelenburg position in the immediate postoperative period.
Provide an ice collar for pain.
The Correct Answer is B
A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.
B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.
C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.
D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polyuria is not commonly associated with heart failure in infants; they are more likely to have oliguria or reduced urine output.
B. Difficulty feeding is a common sign of heart failure in infants because the increased work of breathing and poor cardiac output make it hard for them to feed effectively.
C. Bradycardia is not typically associated with heart failure; tachycardia is more common as the heart tries to compensate for decreased cardiac output.
D. Bradypnea is uncommon in heart failure; tachypnea is a more likely symptom due to fluid overload and poor oxygenation.
Correct Answer is B
Explanation
A. Regular testing of urine for glucose is not specific to nephrotic syndrome and is more relevant for managing diabetes.
B. Weighing the child on the same scale each day is essential for monitoring fluid status and detecting early signs of fluid retention or loss, which are critical in managing nephrotic syndrome.
C. Increasing oral fluid intake may not be recommended due to the risk of fluid retention and edema, which are common in nephrotic syndrome.
D. While monitoring potassium levels is necessary when on diuretics like furosemide, a low-potassium diet is not routinely required unless hyperkalemia is present.
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