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 A
Explanation
A. Withdrawal can be a sign of trauma or distress, including sexual abuse.
B. While destructive behavior can be a reaction to various stressors, it is less specific to sexual abuse.
C. Perfectionistic behavior may be seen in children dealing with various pressures but is not specifically indicative of sexual abuse.
D. Manipulative behavior can be a response to different environmental factors and is not specifically indicative of sexual abuse.
Correct Answer is C
Explanation
A. Sharing toys readily is more common in older preschoolers and school-age children.
B. Having an imaginary playmate typically occurs in children slightly older than 24 months.
C. Parallel play, where children play alongside each other without interacting, is typical for toddlers around 24 months.
D. Asking many questions is more characteristic of preschool-aged children.
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