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
Cholelithiasis refers to the presence of gallstones in the gallbladder or bile ducts. The most common symptom is right upper quadrant abdominal pain, which may be colicky or steady. Nausea and vomiting are also commonly associated with cholelithiasis.
Coffee ground emesis and constipation are not typical findings associated with cholelithiasis. Absent bowel sounds may be a sign of bowel obstruction but are not specific to cholelithiasis.
Correct Answer is D
Explanation
Hip spica casts are typically used to immobilize the hip joint and are often used in the management of hip dysplasia or after surgery. These casts can cause restricted mobility and limit blood flow to the legs and feet, which can lead to complications such as swelling, decreased circulation, or pressure sores.
Checking capillary refill in the toes is a critical nursing intervention to assess for the presence of adequate circulation and blood flow to the affected limb. If capillary refill is slow or absent, it may indicate compromised circulation and require immediate intervention to prevent further complications.
Palpating a brachial pulse, assessing bilateral radial pulses, or auscultating the heart rate apically are not the priority nursing actions for an infant with a hip spica cast. While monitoring vital signs and circulation are important components of nursing care, the priority at this stage is to assess and manage the immediate postoperative needs of the patient, including monitoring for potential complications related to the hip spica cast.
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