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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Collecting a stool specimen for culture is not the preferred method for diagnosing Enterobius vermicularis, as the pinworm eggs are rarely present in the stool.

Choice B reason: Initiating IV fluids is not a diagnostic measure for Enterobius vermicularis and is not relevant unless the child is dehydrated or requires fluids for another reason.

Choice C reason: The tape test is the standard diagnostic procedure for Enterobius vermicularis. It involves placing clear tape around the anus to collect any eggs that may be present, which are then examined under a microscope.

Choice D reason: Testing the stool for occult blood is not a diagnostic measure for Enterobius vermicularis, as this infection does not typically cause bleeding.

A. Administer intramuscularly in the anterolateral thigh. B. Divide the medication into two injections if necessary. C. Use a 22-25 gauge needle. D. Place the child in a comfortable position, preferably sitting upright.

Correct Answer is A

Explanation

Choice A reason: The anterolateral thigh is the recommended site for intramuscular injections in toddlers due to the well-developed muscles and minimal risk of injury to nerves or blood vessels.

Choice B reason: Dividing the medication into two injections may be necessary for large volumes, but influenza vaccines typically do not require this.

Choice C reason: A 22-25 gauge needle is recommended for intramuscular injections in toddlers to minimize discomfort and tissue damage.

Choice D reason: While the supine position is not incorrect, a comfortable sitting position is preferable for toddlers to reduce anxiety and ensure a smooth vaccination process.

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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?

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