Parents of a 3-year-old child diagnosed with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on what knowledge?

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.

The correct answer is choice B. First stage.

Choice A rationale:

There is no fourth stage of Lyme disease. Lyme disease typically progresses through three stages: early localized, early disseminated, and late disseminated. The symptoms mentioned in the question are more indicative of earlier stages of the disease.

Choice B rationale:

The child is likely exhibiting symptoms of the first stage of Lyme disease, known as early localized Lyme disease. This stage is characterized by the appearance of small annular (circular) lesions known as erythema migrans. These lesions are often red and have a clear center, resembling a "bull's-eye" pattern. This stage occurs within days to weeks after a tick bite and is usually accompanied by flu-like symptoms.

Choice C rationale:

There is no third stage of Lyme disease. The third stage is considered the late disseminated stage, which occurs months to years after the initial infection. It typically involves more severe symptoms, such as arthritis, neurological issues, and cardiac abnormalities.

Choice D rationale:

There is no second stage of Lyme disease. The second stage is the early disseminated stage, which occurs weeks to a few months after the tick bite. It involves the spread of the bacteria to other parts of the body, leading to symptoms such as multiple erythema migrans lesions, flu-like symptoms, fatigue, and muscle and joint pain.