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.
The Correct Answer is B
A) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.
B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.
C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.
D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.
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Related Questions
Correct Answer is D
Explanation
Rationale for A: Delegating complicated tasks to an RN might not always be appropriate, especially if the task falls within the scope of the newly licensed nurse. Time management involves prioritizing and organizing tasks effectively, not shifting responsibility unnecessarily.
Rationale for B: Documenting all client care at the end of the shift can lead to missed or inaccurate documentation. It is more efficient to document in real-time or shortly after completing tasks, ensuring accuracy and preventing a backlog of work.
Rationale for C: Performing quick tasks before time-consuming ones may lead to neglecting critical or urgent tasks. Time-consuming tasks might be of higher priority and should be addressed based on urgency rather than the time they take.
Rationale for D: Completing one task before moving on to the next allows the nurse to focus on each task fully, reducing the chance of errors and ensuring that all tasks are completed systematically. This approach improves efficiency and task management.
Correct Answer is B
Explanation
A. Hemoglobin (Hgb) of 12 g/dL is within the normal range for a pregnant individual and does not typically require notification of the provider.
B. Platelet count of 90,000/mm3 is below the normal range (typically 150,000 to 400,000/mm3) and may indicate thrombocytopenia, which can be associated with conditions such as preeclampsia or HELLP syndrome. The nurse should notify the provider about this result.
C. Hematocrit of 37% is within the normal range for a pregnant individual and does not typically require notification of the provider.
D. Creatinine level of 0.7 mg/dL is within the normal range and does not typically require notification of the provider.
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