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: Epiglottitis is a life-threatening condition that causes inflammation and swelling of the epiglottis, the flap of tissue that covers the entrance to the trachea. It can block the airway and cause respiratory distress. The signs and symptoms of epiglottitis include drooling, dysphagia, dysphonia, high fever, and tripod position. Epiglottitis is rare in infants and more common in children aged 2-6 years.
Choice B reason: Bronchiolitis is a viral infection that causes inflammation and mucus production in the bronchioles, the smallest airways in the lungs. It can impair gas exchange and cause respiratory distress. The signs and symptoms of bronchiolitis include sneezing, coughing, nasal congestion, wheezing, tachypnea, retractions, and apneic spells. Bronchiolitis is common in infants and children under 2 years of age, especially during the winter months.
Choice C reason: Influenza is a viral infection that affects the respiratory system. It can cause fever, chills, headache, muscle aches, fatigue, sore throat, cough, and nasal congestion. Influenza can also lead to complications such as pneumonia, otitis media, and sinusitis. Influenza is common in children and adults of all ages, especially during the flu season.
Choice D reason: Croup is a viral infection that causes inflammation and narrowing of the larynx and trachea. It can cause a characteristic barking cough, hoarseness, stridor, and respiratory distress. Croup is common in children aged 6 months to 3 years, especially during the fall and winter months.
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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