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. Constant need to talk about the event. While individuals with PTSD may experience intrusive thoughts or flashbacks related to the traumatic event, a constant need to talk about the event is not universally characteristic. Some individuals with PTSD may avoid discussing the traumatic event altogether due to the distress it causes them, while others may find it helpful to talk about it in therapy or support groups.
B. Increasing feelings of anger. This is the correct choice. Feelings of anger and irritability are common symptoms of PTSD. Individuals may experience heightened levels of anger as a result of feeling violated, powerless, or betrayed by the traumatic event. Anger may be directed toward the perpetrator, oneself, or others, and it can contribute to difficulties in interpersonal relationships and daily functioning.
C. Sleeping 12 hr or more each day. While sleep disturbances are common in PTSD, they typically manifest as insomnia, nightmares, or restless sleep rather than excessive sleep. Individuals with PTSD may struggle to fall asleep, experience frequent awakenings during the night, or have nightmares related to the traumatic event. Excessive sleeping is not typically associated with PTSD.
D. Increasing sense of attachment to others. Individuals with PTSD may experience difficulties in forming or maintaining relationships due to symptoms such as emotional numbing, avoidance of reminders of the trauma, and difficulties in trusting others. While some individuals may seek support from loved ones, an increasing sense of attachment to others is not typically an expected finding in PTSD.
Correct Answer is D
Explanation
A. "You must be getting better. You look great!": This response could potentially be interpreted as positive reinforcement, but it carries the risk of making assumptions about the client's mental state solely based on their appearance. It implies that the client's improved grooming is solely due to their improvement in depression, which may not necessarily be the case. Additionally, it may inadvertently minimize the client's experience of depression by attributing their grooming to improvement rather than recognizing it as an achievement in itself.
B. "Everyone feels better after showering": This response generalizes the client's experience and minimizes the significance of their actions. It implies that grooming is merely a routine activity that everyone does and that feeling better is solely related to physical cleanliness. It fails to acknowledge the client's effort and positive behavior, which could be significant achievements for someone experiencing depression.
C. "Why are you all dressed up today? Is it a special occasion?": This response might put the client on the spot and make them feel uncomfortable or self-conscious about their appearance. It could also imply that there must be a specific reason for the client to take care of their grooming, rather than recognizing it as a positive step regardless of the reason. Additionally, it doesn't acknowledge the client's effort or provide validation for their behavior.
D. "I see you have done some grooming today.": This response acknowledges the client's effort and positive behavior without making assumptions or judgments about the client's mental state or improvement. It demonstrates observance and recognition of the client's actions, which can help build rapport and trust between the nurse and the client. Additionally, it opens the door for further conversation if the client wishes to discuss their grooming habits or how they are feeling.
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