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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the best option to prevent reflux, as it allows gravity to help keep the stomach contents down. The nurse should advise the parent to keep the baby upright for at least 30 minutes after each feeding.
Choice B reason: Positioning the baby side lying during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should instruct the parent to place the baby on the back for sleep, and elevate the head of the crib slightly.
Choice C reason: Thickening the baby's formula with oatmeal may help reduce reflux, but it is not the first choice, as it can cause overfeeding, constipation, or allergic reactions. The nurse should suggest this option only if prescribed by the provider.
Choice D reason: Feeding the baby formula rather than breast milk is not a good option, as breast milk is easier to digest and has many benefits for the baby's health and development. The nurse should encourage the parent to continue breastfeeding, and offer smaller and more frequent feedings.
Correct Answer is C
Explanation
Choice A reason: Absent bowel sounds are not a finding that indicates perforation of the appendix. Absent bowel sounds could be a sign of ileus, obstruction, or peritonitis, but they are not specific to appendicitis.
Choice B reason: Low-grade fever is not a finding that indicates perforation of the appendix. Low-grade fever could be a sign of infection, inflammation, or dehydration, but it is not specific to appendicitis.
Choice C reason: Sudden decrease in abdominal pain is a finding that indicates perforation of the appendix. Sudden decrease in abdominal pain means that the pressure inside the appendix has been released, causing the appendix to rupture and spill its contents into the peritoneal cavity. This can lead to severe complications such as sepsis, abscess, or shock.
Choice D reason: Flaccid abdomen is not a finding that indicates perforation of the appendix. Flaccid abdomen could be a sign of muscle relaxation, sedation, or paralysis, but it is not specific to appendicitis.
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