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 C
Explanation
Choice A reason: Hyperactivity is not typically associated with chronic renal failure in children. Instead, children may experience fatigue and lethargy due to anemia and the overall decreased function of the kidneys.
Choice B reason: Weight gain can occur in chronic renal failure due to fluid retention; however, it is not as characteristic as delayed growth, which is a direct result of the disease's impact on the child's development.
Choice C reason: Delayed growth is a common finding in children with chronic renal failure due to various factors, including metabolic imbalances, bone disorders, and malnutrition, all of which can impede normal growth.
Choice D reason: A flushed face is not a typical finding in chronic renal failure. More common are signs related to fluid overload, such as swelling around the eyes, feet, and ankles, and symptoms of uremia like pallor.
Correct Answer is C
Explanation
Choice A reason: Digoxin is used to treat heart conditions by slowing the heart rate and increasing its efficiency. It does not increase the heart rate. The normal heart rate for a 12-month-old infant ranges from 80 to 160 beats per minute.
Choice B reason: If an infant vomits after taking digoxin, repeating the dose could lead to toxicity. Instead, caregivers should wait until the next scheduled dose or contact a healthcare provider for guidance.
Choice C reason: Administering digoxin at regular intervals ensures consistent therapeutic levels in the bloodstream, which is crucial for the medication's efficacy and safety.
Choice D reason: Offering fluids after medication does not interfere with digoxin's absorption. However, caregivers should be aware of the signs of digoxin toxicity, which include vomiting, lethargy, and bradycardia.
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