A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?

A. Keep the infant in a side-lying position.

This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.

B. Remove elbow restraints while the infant is sleeping.

Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.

C. Administer pain medication around the clock for the first 72 hours.

This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.

D. Feed the infant half-strength formula for the first 48 hours.

This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.

A. "I will restrict the amount of salt in my child's meals."

Restricting salt intake is not typically recommended for children with cystic fibrosis (CF). In fact, individuals with CF often have increased salt requirements due to excessive salt loss through sweat. Restricting salt intake could potentially lead to electrolyte imbalances. Therefore, this statement does not demonstrate an understanding of the dietary management necessary for CF.

B. "I will put my child in daycare to ensure that she socializes with other children."

While socialization is important for a child's development, placing a child with CF in daycare may increase their risk of exposure to respiratory infections, which can be particularly dangerous for individuals with CF due to their compromised respiratory function. Therefore, this statement does not demonstrate an understanding of the infection control measures necessary for managing CF.

C. "I will make sure my child washes her hands before eating.”

This statement demonstrates an understanding of infection control measures, which are crucial for individuals with CF to reduce the risk of respiratory infections. Washing hands before eating helps prevent the transmission of bacteria and viruses that can cause respiratory infections. Therefore, this statement indicates an understanding of an important aspect of managing CF.

D. “I will provide low-fat meals for my child."

Providing low-fat meals is not typically recommended for children with CF. CF often leads to malabsorption of fats, so a diet high in calories and fat is typically recommended to ensure adequate nutrition and weight gain. Therefore, this statement does not demonstrate an understanding of the dietary recommendations necessary for managing CF.