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 C
Explanation
A. An axillary temperature of 37.3° C (99.1° F) is within the normal range for a child and does not need to be reported.
B. A respiratory rate of 24/min is within the normal range for a 6-year-old child and does not need to be reported.
C. A heart rate of 59/min is slightly below the normal range for a 6-year-old and should be reported to the provider.
D. A blood pressure of 96/58 mm Hg is within the normal range for a 6-year-old child and does not need to be reported.
Correct Answer is C
Explanation
A. Swelling in a dependent position is expected due to gravity and should reduce with elevation.
B. Pain following range-of-motion exercises can be normal after a fracture, but persistent or severe pain should be monitored.
C. Coolness of the toes indicates impaired circulation, which can be a sign of compartment syndrome or cast tightness and requires immediate medical attention.
D. Pruritus under the cast is a common complaint and can be managed with appropriate measures but does not require urgent reporting.
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