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 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.
Correct Answer is B
Explanation
Choice A reason: Skin integrity is not a reliable indicator of fluid loss, as it can be affected by other factors such as infection, trauma, or allergy. Skin integrity can be assessed by checking for turgor, elasticity, and color.
Choice B reason: Body weight is a reliable indicator of fluid loss, as it reflects the amount of water and electrolytes in the body. Body weight can be measured by using a calibrated scale and comparing it with the previous or baseline weight.
Choice C reason: Blood pressure is not a reliable indicator of fluid loss, as it can be influenced by other factors such as cardiac output, vascular resistance, and stress. Blood pressure can be measured by using a sphygmomanometer and a stethoscope.
Choice D reason: Respiratory rate is not a reliable indicator of fluid loss, as it can be affected by other factors such as oxygen demand, lung function, and airway obstruction. Respiratory rate can be measured by counting the number of breaths per minute.
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