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. Playing a game of chess with the client: While engaging in activities with the client can be therapeutic, it's essential to consider the client's preferences and level of interest. Some clients with severe depression may not have the motivation or energy to participate in activities like playing chess. Additionally, the focus should be on providing support and empathy rather than suggesting specific activities.
B. Giving the client choices of activities: Offering choices of activities can empower the client and promote autonomy, which is beneficial. However, individuals with severe depression may struggle with decision-making and may feel overwhelmed by choices. Therefore, while offering choices can be therapeutic, it's essential to provide support and guidance in decision-making if needed.
C. Encouraging decision-making: Encouraging decision-making can be beneficial for clients with depression as it promotes a sense of control and self-efficacy. However, individuals with severe depression may find decision-making challenging due to feelings of hopelessness or low energy levels. Therefore, while encouraging decision-making, it's essential to provide support and assistance as needed.
D. Spending time sitting with the client: This is the most therapeutic approach listed. Spending time with the client provides emotional support, companionship, and a nonjudgmental presence, which can be invaluable for someone experiencing severe depression. Simply being present and available to listen without pressure to talk or engage in activities can convey empathy and understanding, fostering a therapeutic nurse-client relationship.
Correct Answer is C
Explanation
A. Limit the amount of time available to interact with others. This statement does not align with the typical behavior of individuals with obsessive-compulsive disorder (OCD). While the client's behavior of constantly picking up after others may indirectly limit interaction time, the primary motivation behind this behavior is more likely related to managing anxiety rather than intentionally limiting social interaction.
B. Manipulate and control others' behaviors. While individuals with OCD may engage in behaviors that affect others, such as seeking reassurance or involving others in their rituals, the behavior described in the scenario does not appear to be aimed at manipulating or controlling others. Instead, it seems driven by the client's internal need to alleviate anxiety through compulsive actions.
C. Decrease anxiety to a tolerable level. This is the correct choice. People with OCD often engage in compulsive behaviors as a way to reduce distressing feelings of anxiety or discomfort. By picking up after others compulsively, the client may experience temporary relief from obsessive thoughts and the associated anxiety. However, the relief is typically short-lived and can lead to a cycle of compulsive behaviors.
D. Focus attention on meaningless tasks. While the behavior of constantly picking up after others may seem repetitive or meaningless to an observer, individuals with OCD typically attribute great significance to their compulsive actions. These behaviors are driven by the need to reduce anxiety or prevent perceived harm rather than a deliberate focus on meaningless tasks.
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