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.
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Related Questions
Correct Answer is B
Explanation
A. Encouraging active range of motion of the extremity can increase swelling and is not recommended immediately after a sprain.
B. Elevating the extremity above the level of the heart helps reduce swelling by promoting venous return.
C. Wrapping the extremity loosely with an elastic bandage provides some support but is not the most effective way to reduce swelling.
D. Applying warm compresses can increase blood flow and swelling; cold compresses are recommended during the first 24 hours.
Correct Answer is B
Explanation
A. Giving the infant a bottle immediately before bedtime is not recommended as it can increase the likelihood of reflux symptoms during sleep. It is better to have some time between feeding and sleeping to allow for digestion.
B. Keeping the infant at a 30° angle for 1 hr following each feeding helps to reduce the risk of reflux by using gravity to keep the stomach contents down. This position can aid in preventing the backflow of stomach contents into the esophagus.
C. Changing to a soy-based formula is not universally recommended for gastroesophageal reflux without a specific indication, such as a confirmed cow's milk protein allergy. It is important to follow a healthcare provider's specific recommendations regarding formula.
D. Limiting feedings to every 6 hours is not appropriate for a 2-month-old infant, who typically requires more frequent feedings to meet nutritional needs and maintain growth.
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