Difficulty: Medium
Average Score: 67%
Full-length
Passage / Scenario
An infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations.Which of the following nursing actions would be MOST appropriate?
Correct answer
C
Rationale
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct, will facilitate drainage of mucus from upper airway, and will promote adjustment to breathing through the nose (4) does not relieve the congestion