A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
Keep the infant in a side-lying position.
Remove elbow restraints while the infant is sleeping
Administer pain medication around the clock for the first 72 hr.
Feed the infant half-strength formula for the first 48 hr
Correct Answer : C,D
A. Keep the infant in a side-lying position.
This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.
B. Remove elbow restraints while the infant is sleeping.
Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.
C. Administer pain medication around the clock for the first 72 hours.
This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.
D. Feed the infant half-strength formula for the first 48 hours.
This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. "You should begin to manipulate the infant's bedtime based on the hospital's visiting hours."
This statement is incorrect. Manipulating the infant's bedtime based on hospital visiting hours may disrupt the infant's regular sleep schedule, potentially causing discomfort and distress. It's important to maintain the infant's routine as much as possible to promote comfort and well-being.
B. "You should bring the infant's favorite blanket to the hospital."
This statement is correct. Bringing the infant's favorite blanket or comfort item can provide familiarity and comfort during the hospital stay. Having familiar items from home can help soothe the infant and reduce anxiety associated with the new environment.
C. "You should read the child a story about hospitalization."
This statement is correct. Reading a story about hospitalization to the child can help prepare them for the upcoming experience and alleviate fear or anxiety. Choosing age-appropriate books that explain what to expect during a hospital stay can help normalize the experience and provide reassurance to the infant and parents.
D. "You will need to go home when it is not visiting hours."
This statement is incorrect. Parents are typically allowed to stay with their infant throughout the hospitalization, especially in the case of pediatric patients. Family presence is important for providing comfort and support to the infant and facilitating bonding during the hospital stay.
Correct Answer is B
Explanation
To calculate the appropriate dose of Theophylline for the child weighing 4.69 kg:
Dose = Weight (kg) × Dose (mg/kg)
Dose = 4.69 kg × 4 mg/kg
Dose = 18.76 mg
So, the appropriate dose is approximately 18.7 mg.
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