The nurse is providing education on tick removal. Which action would be incorrect?

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.

Choice A rationale:

A goiter refers to the enlargement or hypertrophy of the thyroid gland. This can occur due to various reasons, such as iodine deficiency, autoimmune disorders like Hashimoto's thyroiditis, or Graves' disease (which is associated with hyperthyroidism). The thyroid gland produces hormones that regulate metabolism and growth, and when it becomes enlarged, it can lead to visible swelling in the neck.

Choice B rationale:

The posterior pituitary gland is responsible for the release of hormones like vasopressin (antidiuretic hormone) and oxytocin. A goiter is not associated with the posterior pituitary gland. Issues with the posterior pituitary can lead to problems with water balance and uterine contractions, but not thyroid enlargement.

Choice C rationale:

The adrenal glands are responsible for producing hormones like cortisol and adrenaline. While adrenal disorders can lead to various hormonal imbalances, a goiter is not related to adrenal gland function. Adrenal issues might cause symptoms like fatigue, weight changes, and blood pressure irregularities.

Choice D rationale:

The anterior pituitary gland produces hormones that regulate the functions of other endocrine glands, including the thyroid gland. However, a goiter is not directly associated with the anterior pituitary. The anterior pituitary's malfunction can result in disorders like growth hormone deficiency or Cushing's disease, but not thyroid enlargement.