A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?
Apply and release elbow restraints every hour
Keep the infant supine
Feed the infant with a spoon for 48 hours
Suction the mouth with an oral suction tube
The Correct Answer is A
Choice A reason: Applying and releasing elbow restraints every hour prevents the infant from touching or injuring the surgical site, while allowing some movement and circulation. This is a standard nursing intervention for infants who have undergone cleft palate repair.
Choice B reason: Keeping the infant supine is not recommended, as it increases the risk of aspiration and bleeding. The infant should be placed in a side-lying or upright position to facilitate drainage and prevent pressure on the suture line.
Choice C reason: Feeding the infant with a spoon for 48 hours is not necessary, as it may cause discomfort and trauma to the palate. The infant can be fed with a special nipple or a syringe with a rubber tip that delivers small amounts of formula or breast milk to the side of the mouth.
Choice D reason: Suctioning the mouth with an oral suction tube is contraindicated, as it may damage the palate and cause bleeding or infection. The nurse should use a bulb syringe to gently suction the nose and mouth if needed.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Cranberry juice is not a good choice for a child who has had a tonsillectomy, as it is acidic and may cause pain and irritation to the throat. The nurse should avoid offering citrus juices or carbonated beverages to the child.
Choice B reason: Vanilla milkshake is also not a good choice for a child who has had a tonsillectomy, as it is thick and may coat the throat and interfere with healing. The nurse should avoid offering dairy products or foods that are sticky or hard to swallow to the child.
Choice C reason: Cubed ice is not a good choice for a child who has had a tonsillectomy, as it may be too cold and cause vasoconstriction and bleeding. The nurse should avoid offering very cold or very hot fluids to the child.
Choice D reason: Water is the best choice for a child who has had a tonsillectomy, as it is clear, bland, and hydrating. The nurse should encourage the child to drink plenty of water to prevent dehydration and promote healing.
Correct Answer is C
Explanation
Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.
Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.
Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.
Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.
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