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 D
Explanation
A. Fruity breath odor is associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Flushed skin is not a typical symptom of hypoglycemia.
C. Thirst is commonly associated with hyperglycemia.
D. Headache is a common symptom of hypoglycemia due to the lack of glucose supply to the brain.
Correct Answer is B
Explanation
A. Occasional incontinence in a 24-month-old toddler is developmentally appropriate and does not indicate abuse.
B. A spiral fracture in a 6-month-old infant is concerning for potential abuse and should be reported to authorities for further investigation.
C. Exposure to bedbugs and cellulitis, while requiring medical attention, does not necessarily indicate abuse.
D. Sibling rivalry is a common developmental occurrence and does not indicate abuse.
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