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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. 3 months:

By 3 months of age, infants typically experience rapid growth, but their birth weight usually does not double by this time. Infants usually gain weight at a steady rate during the first few months of life, but doubling birth weight typically occurs later in infancy.

B. 9 months:

By 9 months of age, infants continue to grow and develop, but their birth weight usually doubles before this age. While infants may have more than doubled their birth weight by 9 months, it's generally expected to occur earlier in infancy.

C. 6 months:

Correct. Birth weight typically doubles by around 6 months of age. This milestone reflects the rapid growth and development that occurs during the first half-year of life. By 6 months, infants have typically established feeding routines and experienced significant weight gain since birth.

D. 12 months:

By 12 months of age, infants have completed their first year of life, and their growth and development continue at a slightly slower pace compared to earlier months. Doubling birth weight usually occurs earlier, around 6 months, rather than by 12 months.

A. Safety plan B. Behavioral contract C. Dialectical behavior therapy D. Bibliotherapy

Correct Answer is C

Explanation

C. Dialectical behavior therapy (DBT):

Rationale: This is the correct intervention. Dialectical behavior therapy (DBT) is a type of psychotherapy that is specifically designed to treat borderline personality disorder (BPD). It focuses on teaching clients skills to manage their emotions, improve relationships, and cope with distressing situations effectively. Including DBT in the discharge plan for a client with BPD can help them continue their therapeutic progress after leaving the hospital or clinical setting.

Incorrect:

A. Safety plan:

Rationale: While a safety plan may be appropriate for some clients with borderline personality disorder, it is not specific to DBT and may not address the broader range of issues that DBT aims to target. Safety plans typically focus on identifying triggers for self-harm or suicidal ideation and outlining steps for managing crises, whereas DBT encompasses a more comprehensive approach to managing emotions and behaviors.

B. Behavioral contract:

Rationale: Behavioral contracts are agreements between individuals and their treatment providers that outline specific behaviors, consequences, and rewards. While behavioral contracts may be used as part of a comprehensive treatment plan for clients with BPD, they do not specifically address the skills-based approach of DBT.

D. Bibliotherapy:

Rationale: Bibliotherapy involves the use of written materials, such as self-help books or educational resources, to support therapeutic goals. While reading materials may complement DBT and other therapeutic approaches, bibliotherapy alone is not considered a primary intervention for treating borderline personality disorder.

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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?

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