A nurse is reinforcing teaching with the parents of a 10-week-old infant who is scheduled for surgical repair of a cleft lip. Which of the following pieces of information should the nurse include?
"You should give your baby a pacifier when she cries."
"Your baby will be placed in elbow restraints following surgery."
"Your baby cannot have anything by mouth until 2 hours after surgery."
"You should position your baby on her abdomen following surgery.".
The Correct Answer is B
The correct answer is choice b. “Your baby will be placed in elbow restraints following surgery.”
Choice A rationale:
Giving a pacifier to a baby after cleft lip surgery is generally not recommended as it can put pressure on the surgical site and potentially disrupt the healing process.
Choice B rationale:
Elbow restraints are used to prevent the infant from touching or rubbing the surgical site, which helps in protecting the stitches and ensuring proper healing.
Choice C rationale:
Infants are usually allowed to have fluids by mouth soon after surgery, often within a few hours, to ensure they stay hydrated and to monitor their ability to swallow.
Choice D rationale:
Positioning the baby on their abdomen is not recommended as it can put pressure on the surgical site. Instead, the baby should be positioned on their back or side to avoid any pressure on the repaired lip
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Extremities warm to the touch. This manifestation is not indicative of decreased cardiac output. Warm extremities suggest adequate peripheral perfusion and circulation. In a child with decreased cardiac output, the body might attempt to shunt blood away from the extremities to prioritize vital organs, leading to cooler extremities.
Choice B rationale:
Capillary refill 2 seconds. A capillary refill time of 2 seconds is within the normal range for a preschool-aged child. This quick capillary refill suggests adequate circulation and is not a sign of decreased cardiac output. Prolonged capillary refill time might be indicative of poor peripheral perfusion.
Choice C rationale:
Blood pressure 112/66 mm Hg. While a blood pressure of 112/66 mm Hg might be within the normal range for a preschooler, it is not the most reliable indicator of decreased cardiac output. Blood pressure can be influenced by various factors, and a seemingly normal blood pressure does not rule out decreased cardiac output if other manifestations are present.
Choice D rationale:
Diminished pulses. This is the correct choice. Diminished or weak pulses are indicative of decreased cardiac output. Inadequate blood volume being pumped by the heart can lead to reduced peripheral perfusion, resulting in diminished pulses. This sign is important in assessing the child's cardiovascular status postoperatively, especially after a corrective procedure for tetralogy of Fallot.
Correct Answer is D
Explanation
Choice A rationale:
Hematocrit 36%. A hematocrit level of 36% falls within the normal range for adolescents. Hematocrit measures the proportion of blood volume occupied by red blood cells and is used to assess for anemia or polycythemia. A level of 36% is not a cause for concern in this case.
Choice B rationale:
Hemoglobin 12 g/dL. A hemoglobin level of 12 g/dL is within the normal range for adolescents. Hemoglobin is a protein in red blood cells that carries oxygen. This level indicates that the adolescent is not significantly anemic.
Choice C rationale:
Glucose 120 mg/dL. A glucose level of 120 mg/dL is within the normal range for a random blood glucose test. However, in the context of diabetes mellitus, the nurse should be more concerned about the HbA1c level, which reflects the average blood glucose level over the past few months.
Choice D rationale:
HbA1c 10.7%. HbA1c, or glycated hemoglobin, reflects the average blood glucose concentration over a span of approximately 2 to 3 months. An HbA1c level of 10.7% is significantly elevated and indicates poor long-term glucose control. This value suggests that the adolescent's diabetes management has not been effective, which can lead to an increased risk of diabetes-related complications over time. The nurse should notify the healthcare provider so that appropriate adjustments can be made to the treatment plan.
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