The nurse, caring for an infant whose cleft lip was repaired, should include which interventions in the infant's postoperative plan of care? (Select all that apply.).
Petroleum jelly to the suture line.
Elbow restraints.
Supine and side-lying positions.
Mouth irrigations.
Postural drainage.
Correct Answer : A,B,D
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.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. It is a belief common at this age.
Choice A rationale:
The statement does not suggest a failed attempt to develop a conscience. The scenario described is more related to the cognitive development of an 8-year-old child. Children at this age often have magical thinking and may interpret events, such as illness, as punishments for perceived wrongdoing. This is a normal aspect of their cognitive development rather than a reflection of a failed attempt to develop a conscience.
Choice B rationale:
While beliefs about punishment and consequences are present in many religions, the scenario is not about a general religious belief but rather a specific belief held by the individual child. This belief is reflective of the child's cognitive understanding and not necessarily a religious teaching common to most religions.
Choice C rationale:
The belief is not necessarily suggestive of excessive family pressure. While family dynamics can influence a child's beliefs and behaviors, the scenario describes a typical cognitive developmental stage where children are still learning to differentiate between reality and their own thoughts, leading to magical thinking and unique interpretations.
Choice D rationale:
The belief is indeed common at this age. During middle childhood, children often exhibit concrete operational thinking, which includes a tendency to interpret events in a self-centered and concrete manner. Beliefs like the one described in the scenario, where the child connects her illness to perceived bad behavior and potential consequences, are characteristic of this developmental stage.
Correct Answer is C
Explanation
The correct answer is choice C. Decreased oxygen-carrying capacity of blood.
Choice A rationale:
Anemia does not primarily result in a depressed hematopoietic system. In fact, anemia often occurs due to various factors that affect red blood cell production or lifespan. The hematopoietic system can be overactive in response to anemia, attempting to compensate for the reduced oxygen-carrying capacity of the blood.
Choice B rationale:
While some anemias may involve the presence of abnormal hemoglobin (e.g., sickle cell anemia), this is not the primary result of anemia. The primary consequence of anemia is a decreased ability of the blood to carry oxygen to the body's tissues.
Choice C rationale:
The correct choice. Anemia leads to a decreased oxygen-carrying capacity of the blood. Hemoglobin, the protein in red blood cells responsible for carrying oxygen, is reduced in quantity or function in various types of anemia. This results in inadequate oxygen delivery to tissues, potentially causing symptoms such as fatigue, weakness, pallor, and shortness of breath.
Choice D rationale:
Increased blood viscosity is not a primary result of anemia. Anemia tends to reduce blood viscosity because there are fewer red blood cells and less hemoglobin present, which makes the blood more fluid and less viscous. Increased blood viscosity is more commonly associated with conditions like polycythemia, where there is an excess of red blood cells.
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