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

Answer and Explanation

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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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.

A. The pulse oximeter might not be accurate during times of excessive movement. B. We will notify the doctor if the pulse oximeter consistently reads 100%. C. We will rotate the probe of the pulse oximeter every 24 hours. D. The probe of the pulse oximeter can be applied to a finger or a toe.

Correct Answer is C

Explanation

Choice A reason: This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.

Choice B reason: A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.

Choice C reason: The probe placement does not need to be rotated every 24 hours. Once the probe is correctly positioned (usually on a finger or toe), it can remain in place for continuous monitoring without needing frequent adjustments.

Choice D reason: This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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