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 A
Explanation
A. Drink eight glasses of fluid daily: This is crucial advice for patients with sickle cell anemia, as adequate hydration helps prevent sickling of red blood cells and reduces the risk of vaso-occlusive crises. Therefore, this precaution is appropriate and should be included in discharge teaching.
B. Maintain an updated Haemophilus influenzae type b (Hib) immunization: While vaccination is essential for overall health, maintaining Hib immunization is not directly related to sickle cell anemia or vaso-occlusive crises. However, it's still important for the child's general well-being and should be addressed but may not be the priority in discharge teaching for sickle cell anemia.
C. Avoid playground activities at school: Children with sickle cell anemia are at risk of vaso-occlusive crises triggered by dehydration, fatigue, or extreme physical exertion. While playground activities can be strenuous, completely avoiding them may not be necessary. Instead, the child should be educated on the importance of staying hydrated, taking breaks when needed, and avoiding excessive physical strain.
D. Assume postural drainage positions every 6 hours: Postural drainage is not typically indicated for sickle cell anemia or vaso-occlusive crises unless there are specific respiratory complications. This precaution is not relevant to the management of sickle cell anemia and should not be included in discharge teaching for this condition.
Correct Answer is B
Explanation
A. "When I use this technique the medication will not run out of the ear."
This explanation is not entirely accurate. While pulling the auricle down and back may help prevent ear drops from immediately dripping out of the ear, the primary purpose of this technique is to straighten the ear canal, facilitating the passage of the medication into the inner ear region for optimal effectiveness. The prevention of medication runoff is a secondary benefit.
B. “This opens the ear canal, allowing medication to reach the inner ear region.”
This explanation is correct. Pulling the auricle down and back helps to straighten the ear canal, making it easier for the ear drops to enter the ear canal and reach the inner ear where they can effectively treat the condition. This is the main purpose of using this technique.
C. “This is the safest and easiest way to administer this medication.”
While pulling the auricle down and back is a commonly used technique for administering ear drops, describing it as the safest and easiest way may not fully capture its purpose. Safety and ease of administration are important considerations, but the primary rationale for this technique is to facilitate the delivery of medication to the inner ear.
D. “When I use the technique, your child experiences less pain.”
This explanation is inaccurate. Pulling the auricle down and back may not directly reduce pain. The main purpose of this technique is to ensure that the medication reaches the inner ear region for effective treatment. While discomfort during administration may be minimized with proper technique, the primary focus is on medication delivery rather than pain reduction.
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