A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature.
Restrain the infant's wrists.
Place the infant in a prone position.
Gently clean the suture line with povidone-iodine solution.
The Correct Answer is A
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will take my child's rectal temperature daily.": Taking a rectal temperature in a child receiving chemotherapy is not recommended because it increases the risk of rectal injury and infection. An oral or axillary temperature is preferred.
B. "I will make sure to inspect my child's mouth every day for sores." Chemotherapy suppresses the immune system, leaving the child vulnerable to infections such as mucositis. Inspecting the mouth daily is crucial to detect any sores or signs of infection early and prevent complications.
C. "I will make sure my child gets their MMR vaccine this week.": Live vaccines like the MMR (measles, mumps, rubella) vaccine should not be given during chemotherapy or other forms of immunosuppressive treatment.
D. "I will ensure my child exercises a little each day by riding their bicycle.": Exercise may be limited during chemotherapy due to fatigue and increased susceptibility to infection. Physical activity should be tailored to the child's ability and energy level, not mandated.
Correct Answer is B
Explanation
A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.
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