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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Barking cough is not a finding that indicates the effectiveness of the treatment. Barking cough is a sign of inflammation of the larynx and trachea, which causes a hoarse and harsh sound. It is a common symptom of acute laryngotracheobronchitis, also known as croup.
Choice B reason: Decreased stridor is a finding that indicates the effectiveness of the treatment. Stridor is a high-pitched, wheezing sound that occurs when the airway is narrowed or obstructed. It is a sign of respiratory distress and hypoxia. The cool mist tent helps to humidify and soothe the airway, reducing the swelling and inflammation.
Choice C reason: Decreased temperature is not a finding that indicates the effectiveness of the treatment. Decreased temperature could be a sign of hypothermia or sepsis, which are serious complications that require immediate attention. The normal temperature range for a toddler is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice D reason: Improved hydration is not a finding that indicates the effectiveness of the treatment. Improved hydration is a sign of adequate fluid intake and output, which are important for maintaining electrolyte balance and preventing dehydration. However, hydration status does not directly affect the airway inflammation or obstruction.
Correct Answer is D
Explanation
Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.
Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.
Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.
Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.
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