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.
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Related Questions
Correct Answer is D
Explanation
A. Place a heated fan at the bedside to facilitate drying: Using a heated fan can increase the risk of burns to the child's skin underneath the cast. The drying process for a cast should occur naturally, and artificial heat sources should not be used.
B. Support the casted arm with a firm grasp: While it's important to support the child's arm during the casting procedure, doing so with a firm grasp may not be necessary or appropriate. The nurse should follow the orthopedic surgeon's instructions regarding the positioning and support of the arm during casting.
C. Tell the child, "This will make your arm feel better": This statement may not accurately reflect the purpose of the cast, as casting is typically done to immobilize and protect the injured limb during the healing process. It's important to provide developmentally appropriate explanations to children about medical procedures, but this particular statement may not be helpful or accurate in this context.
D. Wrap the arm of the child's doll or toy prior to the procedure: This action helps familiarize the child with the procedure and can serve as a form of therapeutic play. By involving the child's toy or doll, the nurse can help reduce anxiety and fear associated with the casting procedure. It also provides an opportunity for the child to understand what will happen to their own arm, promoting a sense of familiarity and control over the situation.
Correct Answer is C
Explanation
A. Half-strength infant formula: Infant formula, even if diluted, may not be appropriate immediately after a repair of intussusception. It may be too heavy for the infant's digestive system, potentially leading to complications. Clear fluids are usually preferred initially.
B. Sterile water: Sterile water is not typically recommended for oral intake in infants after a repair of intussusception. It lacks essential electrolytes needed to maintain proper hydration and electrolyte balance.
C. Oral electrolyte solution: Oral electrolyte solutions, such as Pedialyte, are often recommended for infants after a repair of intussusception. These solutions contain balanced electrolytes and fluids, which help prevent dehydration and restore electrolyte balance.
D. Half-strength orange juice: Orange juice, even if diluted, is not typically recommended immediately after a repair of intussusception. It may be too acidic and may cause gastrointestinal discomfort or irritation in the infant. Clear fluids are preferred initially to allow the gastrointestinal tract to rest and recover.
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