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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A semi-private room with a roommate who has a similar diagnosis. Placing a client experiencing a manic episode in a semi-private room with another client who also has a similar diagnosis could potentially exacerbate symptoms or lead to conflict. Manic clients may have increased energy levels, impulsivity, and decreased need for sleep, which could disrupt the roommate's rest and compromise their safety.
B. A private room close to the nursing station. Assigning a private room close to the nursing station is the most appropriate option for a client in the manic phase of bipolar disorder. This allows for closer monitoring and supervision by nursing staff, as well as easier access for interventions and assistance when needed. It also helps to minimize stimulation and provide a more controlled environment for the client.
C. A private room in a quiet location on the unit. While a quiet location may be beneficial for some clients, a private room close to the nursing station offers better access to supervision and support from staff, which is particularly important for clients experiencing mania. Additionally, a quiet location may not always be feasible in a busy psychiatric unit.
D. A seclusion room until the client's activity level becomes more subdued. Using a seclusion room should only be considered as a last resort and when absolutely necessary to ensure the safety of the client and others. It should not be the first choice for a client in the manic phase of bipolar disorder. Placing the client in seclusion may further escalate agitation and increase feelings of isolation and distress.
Correct Answer is C
Explanation
A. Restrain the child physically: Physically restraining a toddler during a temper tantrum can escalate the situation and may lead to the child feeling scared or more frustrated. It's important to avoid physical force as it can be traumatic for the child and potentially harmful.
B. Ignore the temper tantrums: Ignoring temper tantrums might work in some situations, but it's not always the most effective strategy. Toddlers often tantrum to seek attention or express frustration, and ignoring them entirely may not address the underlying issue. Additionally, consistent ignoring can lead to feelings of abandonment or exacerbate the behavior.
C. Distract the child by offering to play a game: Distraction can be an effective technique for managing temper tantrums in toddlers. Offering to engage the child in a fun activity or game can redirect their focus away from the source of frustration, helping to de-escalate the situation and promote positive behavior.
D. Tell the child that temper tantrums are not acceptable: While it's important to set boundaries and teach appropriate behavior, telling a toddler that temper tantrums are not acceptable may not effectively address the immediate situation. Toddlers may not fully understand or be able to control their emotions, so simply telling them that tantrums are unacceptable without providing alternative coping strategies is unlikely to be effective.
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