During the first few days after surgery for cleft lip, which intervention should the nurse implement?
Apply Neosporin to avoid Infection.
Apply elbow immobilizers when not being held.
Suction secretions away from the suture line.
Feed Increased amounts of formula to prevent weight loss.
The Correct Answer is C
Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.
Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.
Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.
Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.
DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications
Correct Answer is C
Explanation
Bowel sounds are the result of muscular contractions in the intestines, indicating the movement of food, fluids, and gas through the gastrointestinal tract. After surgery, the normal function of the intestines, including peristalsis, may be temporarily impaired. As the intestines recover and regain their normal motility, bowel sounds will become audible.
The return of bowel sounds is an encouraging sign that the gastrointestinal system is starting to function again. It indicates that peristaltic activity has resumed and that the intestines are moving and processing the contents within. This is an essential step in the postoperative recovery process, as it indicates the return of normal gastrointestinal function and can lead to the resumption of oral intake and passage of stool.
While the other options may also be associated with the return of GI function, such as feeling hungry or passing flatus or stool, the presence of bowel sounds is a more reliable and direct assessment finding that indicates the resumption of peristaltic activity.
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