A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse Include?

Allow the infant to have soft foods.

Maintain elbow restraints on the infant.

Instruct the parents to feed the infant with a spoon.

Tell the parents to avoid brushing the infant's teeth for two weeks.

Answer and Explanation

The Correct Answer is B

A. Allow the infant to have soft foods: After cleft palate repair, oral intake is typically restricted to prevent trauma to the surgical site. Soft or solid foods can disrupt sutures and increase the risk of bleeding or infection. Oral intake is usually limited to clear liquids or specially prepared feeds until healing is sufficient.

B. Maintain elbow restraints on the infant: Elbow restraints (arm splints) help prevent the infant from touching or putting fingers or objects in the mouth, which could damage the surgical site. This intervention protects the integrity of the repair during the critical postoperative healing period and reduces the risk of complications such as dehiscence or infection.

C. Instruct the parents to feed the infant with a spoon: Spoon feeding can apply pressure to the palate and sutures, potentially causing trauma to the repair site. Feeding is often done using specialized devices such as a syringe, cup, or soft-tipped feeders designed to minimize contact with the surgical area.

D. Tell the parents to avoid brushing the infant's teeth for two weeks: Oral hygiene is still important after cleft palate repair, but brushing must be gentle to avoid trauma. Complete avoidance is unnecessary; instead, the nurse should instruct parents to use soft-bristled brushes and avoid the immediate surgical site while maintaining overall oral cleanliness.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Subcutaneous: The subcutaneous route deposits medication into the fatty tissue beneath the skin. PPD testing requires a slow, localized immune reaction, which cannot be accurately assessed if administered subcutaneously, making this route inappropriate.

B. Intramuscular: Intramuscular injections deliver medication into muscle tissue for systemic absorption. PPD relies on a localized delayed-type hypersensitivity reaction in the dermis, so IM administration would prevent accurate interpretation of the test.

C. Intradermal: PPD is administered intradermally, usually on the inner forearm, to produce a small, raised wheal. This allows for proper exposure of immune cells in the dermis to the antigen, enabling assessment of induration 48–72 hours later and accurate detection of tuberculosis exposure.

D. Oral: Oral administration does not provide a localized skin reaction necessary for PPD testing. The immune response required for interpreting the test cannot occur via the gastrointestinal route, making oral administration inappropriate.

A. Decreased blood pressure B. Pale yellow urine C. Periorbital edema D. Increased urination

Correct Answer is C

Explanation

A. Decreased blood pressure: In acute glomerulonephritis, fluid retention and sodium accumulation often lead to hypertension rather than hypotension. Decreased blood pressure would be unusual and could indicate another underlying issue.

B. Pale yellow urine: Clients typically present with hematuria, which causes tea-colored or cola-colored urine, not pale yellow. The discoloration results from red blood cells leaking into the urine due to glomerular inflammation.

C. Periorbital edema: Fluid retention is common in acute glomerulonephritis, particularly in the face and around the eyes. Edema results from decreased glomerular filtration and sodium/water retention, making periorbital swelling a classic and expected finding.

D. Increased urination: Oliguria, or decreased urine output, is more typical in acute glomerulonephritis due to impaired renal function. Polyuria is not usually associated with this condition unless complications like diabetes insipidus are present.

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A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse Include?

Nursing Test Bank

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