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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. After taking antibiotics for 24 hours.
Choice A rationale:
Returning to school if no complications develop is not a sufficient guideline for allowing a child with streptococcal pharyngitis to return to school. Streptococcal pharyngitis (strep throat) is highly contagious, and children should be treated with antibiotics to prevent the spread of the infection.
Choice B rationale:
Waiting until the sore throat is better is not a specific enough criterion for returning to school. While the resolution of symptoms is an important factor, it's crucial to ensure that the child has also been on antibiotics for an appropriate duration to reduce the risk of spreading the infection to others.
Choice C rationale:
The recommended guideline is to return to school after taking antibiotics for 24 hours. This timeframe helps ensure that the child's contagiousness is significantly reduced, minimizing the risk of transmitting the infection to classmates and school staff.
Choice D rationale:
Waiting for three days after taking antibiotics is not as precise as waiting for 24 hours. With proper antibiotic treatment, the child's contagiousness decreases rapidly, and waiting for three days might be unnecessary and could potentially result in more missed school days than needed.
Correct Answer is B
Explanation
The correct answer is choice b. Grasp the tick by the body to remove.
Choice A rationale:
Cleansing the wound with soap and water is a correct action. It helps to prevent infection after the tick has been removed.
Choice B rationale:
Grasping the tick by the body is incorrect. The proper method is to use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible and pull upward with steady, even pressure. Grasping the tick by the body can cause the mouth-parts to break off and remain in the skin, increasing the risk of infection.
Choice C rationale:
Leaving the tick in place and seeking emergency medical treatment is not recommended. The tick should be removed as soon as possible to reduce the risk of disease transmission.
Choice D rationale:
Avoiding touching the tick with bare hands is correct. Using gloves or tissue to handle the tick helps prevent the transmission of pathogens.
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