A nurse is caring for an infant who is postoperative following repair of a cleft palate. Which of the following is an appropriate action by the nurse?
Gently cleanse the surgical site with sterile gauze.
Place the infant in a supine position.
Apply elbow immobilizers to both arms.
Offer a pacifier with glucose syrup.
The Correct Answer is C
A. Cleansing the surgical site is not typically recommended as it can interfere with healing and cause trauma to the area. The surgical site should be kept clean and dry according to the surgeon's instructions.
B. Placing the infant in a supine position is not recommended as it can increase the risk of aspiration and disrupt the surgical site. Positioning should be done to protect the surgical repair.
C. Applying elbow immobilizers to both arms prevents the infant from touching or putting their hands in their mouth, which helps to protect the surgical site from injury and allows it to heal properly.
D. Offering a pacifier with glucose syrup is not appropriate as sucking on a pacifier can disrupt the surgical site and glucose syrup is not necessary in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An oatmeal bath can soothe the skin but is not the immediate first step.
B. Flushing the area with cold, running water helps remove the plant oils that cause the reaction and is the first step in managing poison ivy exposure.
C. Administering an oral corticosteroid may be necessary for severe reactions but is not the first action to take.
D. Calamine lotion can help with itching but should be applied after washing off the plant oils.
Correct Answer is D
Explanation
A. IV fluid therapy may be necessary if the child cannot tolerate oral fluids, but oral rehydration therapy is the first line of treatment for mild to moderate dehydration.
B. Administering a regular diet is important for recovery but is not the priority action when addressing acute dehydration.
C. IV antibiotics are not typically necessary for acute diarrhea unless there is a confirmed bacterial infection.
D. Initiating oral rehydration therapy is the priority to address dehydration and replace lost fluids and electrolytes effectively.
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