A nurse is caring for an infant who has just returned from the PACU following cleft lip and palate repair. Which of the following actions should the nurse take?
Assess the mouth with a tongue blade.
Remove the packing in the mouth.
Place the infant in an upright position.
Offer a pacifier with sucrose.
The Correct Answer is C
Choice A reason: Assessing the mouth with a tongue blade is not recommended postoperatively as it can cause discomfort and disrupt the surgical site.
Choice B reason: Removing the packing in the mouth is typically done by a healthcare provider, not immediately postoperatively, to avoid bleeding and protect the repair.
Choice C reason: Placing the infant in an upright position is recommended to facilitate breathing and reduce swelling⁷.
Choice D reason: Offering a pacifier with sucrose is not advisable as it can interfere with the healing of the cleft repair⁷.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: A sensation of being cold can occur as the body's circulation diminishes and blood flow to the extremities decreases.
Choice B reason: A heightened sense of hearing is not typically a sign of impending death; this choice is incorrect.
Choice C reason: Difficulty swallowing can be a sign of impending death due to the body's muscles weakening and a decrease in reflexes.
Choice D reason: Tachycardia may occur as the heart tries to compensate for decreased function in other systems.
Choice E reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing, are a common sign of impending death.
Correct Answer is A
Explanation
Choice A reason: Oral rehydration therapy is the first-line treatment for dehydration due to diarrhea, as it effectively restores fluid and electrolyte balance.
Choice B reason: While chicken broth may provide some salt, it lacks the necessary electrolytes and glucose needed for effective rehydration.
Choice C reason: A hypertonic IV solution is not typically used for dehydration due to diarrhea, as it can exacerbate fluid shifts and dehydration.
Choice D reason: Keeping a child NPO is not recommended as it can lead to further dehydration and delay recovery.
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