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
Explanation
Choice A reason: Separation anxiety is common in early childhood and typically resolves as the child develops, usually by around age 2 or 3.However, it can also be present in school-age children, especially if it develops into separation anxiety disorder.
Choice B reason: This is not typically included in teaching about separation anxiety. Detachment might be a response to prolonged separation or hospitalization, but it is not a stage of separation anxiety.
Choice C reason:
While kicking a stranger can be a manifestation of separation anxiety, it’s more constructive to focus on common symptoms such as excessive worry when apart from home or family, or panic and fear at the time of separation
Choice D reason: Separation anxiety that is severe and persistent can lead to challenges in adaptability and functioning. It’s important for caregivers to recognize symptoms and seek help if the anxiety interferes with daily life.
Correct Answer is B
Explanation
Choice A reason: Removing personal objects from the room is not reflective of palliative care principles, which focus on comfort and personal significance.
Choice B reason: Listening and responding to the family's discussions about their child's life aligns with the holistic approach of palliative care, which includes emotional support.
Choice C reason: Expressing personal feelings of missing the client is not indicative of an understanding of palliative care roles and responsibilities.
Choice D reason: Being hopeful about new medications is not relevant to palliative care, which focuses on quality of life rather than curative treatment.
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