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 ["B","C","D"]
Explanation
Choice A reason: The inability to retract foreskin is not typically associated with epispadias. This condition is characterized by the urethral opening being on the dorsal side of the penis.
Choice B reason: In epispadias, the urethral opening is located on the dorsal side of the penis, which is a key characteristic of this condition.
Choice C reason: A widened pubic symphysis is often seen in epispadias due to the associated pelvic bone structure abnormalities.
Choice D reason: Bladder exstrophy is commonly associated with epispadias and involves the bladder being exposed outside the abdomen.
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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