A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis?

The correct answers are choices A, B, and D.

Choice A rationale:

Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.

Choice B rationale:

Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.

Choice C rationale:

While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.

Choice D rationale:

Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.

Choice E rationale:

Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.

Answer is: d. Apply direct pressure above the catheterization site.

Explanation: The first action should be to apply direct pressure above the catheterization site to help control the bleeding and minimize blood loss. This will also give the nurse time to prepare additional interventions or supplies if necessary.

Choice a. is wrong because placing the child in the Trendelenburg position is not an appropriate initial nursing action in this scenario. This position can increase intracranial pressure and is typically used for patients experiencing shock or hypotension.

Choice b. is wrong because applying a new bandage with more pressure might be a subsequent action, but the priority is to apply direct pressure to slow down the bleeding.

Choice c. is wrong because notifying the physician is important, but the nurse should first take immediate action to control the bleeding and minimize potential harm to the patient.