Difficulty: Medium
Average Score: 86%
Simulated
Passage / Scenario
A 4-month-old infant who is one day postoperative following surgical repair of a cleft lip.A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply
Correct answer
A,D,E
Rationale
Correct Answer: A,D,E
Rationale:
A: Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and promotes airway patency.
D: Applying elbow restraints as ordered helps prevent the infant from inadvertently touching or scratching the surgical site.
E: Maintaining IV therapy for nutrition ensures the infant receives adequate hydration and nutrition postoperatively.
Summary:
B: Encouraging the parents to hold the baby is generally beneficial for bonding and comfort but not specific to postoperative care.
C: Administering aspirin for pain is contraindicated in infants due to the risk of Reye syndrome.
F: No information provided.
G: No information provided.
Rationale:
A: Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and promotes airway patency.
D: Applying elbow restraints as ordered helps prevent the infant from inadvertently touching or scratching the surgical site.
E: Maintaining IV therapy for nutrition ensures the infant receives adequate hydration and nutrition postoperatively.
Summary:
B: Encouraging the parents to hold the baby is generally beneficial for bonding and comfort but not specific to postoperative care.
C: Administering aspirin for pain is contraindicated in infants due to the risk of Reye syndrome.
F: No information provided.
G: No information provided.