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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Positioning a child supine after a tonsillectomy is not recommended due to the risk of respiratory complications. Elevating the head of the bed is preferred to prevent aspiration and facilitate breathing.
Choice B reason: Administering analgesics on a schedule is crucial for effective pain management. It helps maintain consistent pain relief, which is important for encouraging fluid intake and preventing dehydration.
Choice C reason: Encouraging a child to blow their nose gently after a tonsillectomy is not advised because it can increase the risk of bleeding. Instead, gentle mouth breathing and avoiding nose blowing are recommended.
Choice D reason: Offering orange juice after a tonsillectomy is not ideal as acidic beverages can irritate the throat. It's better to provide non-acidic fluids like water or apple juice to keep the child hydrated.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Clubbing of the fingers is not typically associated with coarctation of the aorta; it is more commonly seen in chronic hypoxia conditions.
Choice B reason: Weak femoral pulses are expected in coarctation of the aorta due to the narrowing of the aorta, which can reduce blood flow to the lower extremities.
Choice C reason: Cool skin of the lower extremities can be a result of decreased blood flow due to the narrowed aorta in coarctation.
Choice D reason: High blood pressure is more commonly associated with coarctation of the aorta, especially in the upper body, due to the narrowing of the aorta increasing resistance to blood flow⁷.
Choice E reason: Severe cyanosis can occur in coarctation of the aorta if there is a significant obstruction to blood flow, leading to poor oxygenation.
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