A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?
Feed the infant with a spoon for 48 hr.
Apply and release elbow restraints every hour.
Keep the infant supine
Suction the mouth with an oral suction tube.
The Correct Answer is B
A. Feed the infant with a spoon for 48 hr.
Following cleft palate repair, infants may need special feeding techniques to minimize the risk of injury to the surgical site. Feeding with a spoon is a gentle method that reduces the risk of trauma to the repaired palate. However, it is typically recommended for a longer duration than 48 hours, often until the surgical site is fully healed and the healthcare provider provides further instructions. Therefore, this option is not entirely accurate.
B. Apply and release elbow restraints every hour.
Elbow restraints are commonly used postoperatively in infants to prevent them from inadvertently touching or scratching the surgical site. Releasing and reapplying the restraints every hour helps prevent skin breakdown and ensures adequate circulation to the extremities. This intervention helps maintain the integrity of the surgical repair and reduces the risk of complications. Therefore, this is an appropriate intervention for an infant post cleft palate repair.
C. Keep the infant supine
While keeping the infant supine may be necessary to prevent aspiration and promote comfort, it is not the primary intervention to address the surgical repair of the cleft palate. Positioning recommendations may vary based on the surgeon's preferences and the infant's specific needs, but supine positioning alone does not address the prevention of trauma to the surgical site.
D. Suction the mouth with an oral suction tube.
Suctioning the mouth with an oral suction tube may be indicated to maintain airway patency and remove secretions, especially if the infant has difficulty swallowing or clearing oral secretions effectively. However, it is not typically specified as a routine intervention following cleft palate repair unless there are specific concerns about airway compromise or excessive secretions. Therefore, while it may be necessary in some cases, it is not a standard intervention for all infants post cleft palate repair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide a structured activity schedule for the client: While providing a structured activity schedule can be beneficial for clients with OCD, it may not be the first action the nurse should take. Before implementing such a schedule, it is essential to understand the underlying factors contributing to the client's ritualistic behaviors.
B. Identify precipitating factors for ritualistic behaviors: This is the first action the nurse should take when caring for a client with OCD. By identifying the triggers or precipitating factors that lead to the client's ritualistic behaviors, the nurse can develop a targeted plan of care to address these specific triggers and help the client manage their symptoms more effectively.
C. Instruct the client on relaxation techniques for use when anxiety increases: While relaxation techniques can be helpful for managing anxiety associated with OCD, identifying precipitating factors should be addressed first to understand the specific triggers contributing to the client's anxiety and ritualistic behaviors.
D. Discuss alternative coping strategies with the client: Exploring alternative coping strategies is an important aspect of caring for clients with OCD, but it should come after identifying precipitating factors. Once triggers are identified, the nurse and client can collaboratively develop and implement alternative coping strategies tailored to the client's specific needs and triggers.
Correct Answer is B
Explanation
A. "Who is lying about you and trying to poison you?": This response may come across as confrontational and may not effectively address the client's underlying fear or paranoia. It could potentially escalate the client's anxiety or reinforce their delusions by implying that the nurse believes the accusations are valid.
B. "You seem to be having very frightening thoughts.": This response acknowledges the client's experience without directly challenging or validating the content of their delusions. It conveys empathy and concern while also opening the door for further exploration of the client's feelings and experiences. By acknowledging the frightening nature of the client's thoughts, the nurse demonstrates understanding and provides an opportunity for therapeutic dialogue.
C. "You are mistaken. Nobody is lying about you or trying to poison you.": This response denies the client's reality and contradicts their experience, which can be invalidating and may cause the client to feel misunderstood or dismissed. It's important to avoid outright denial of the client's beliefs, as it can damage the therapeutic relationship and hinder effective communication.
D. "Why do you think you are being lied about and poisoned?": While this response seeks to explore the client's thoughts and feelings, it may be perceived as challenging or confrontational. It could unintentionally reinforce the client's delusions by inviting them to elaborate on their paranoid beliefs without first acknowledging the distress they are experiencing.
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