Difficulty: Medium
Average Score: 81%
Simulated
Passage / Scenario
A 4-month-old infant who is one day postoperative following surgical repair of a cleft lipA 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, promotes drainage, and reduces stress on the surgical site.
D: Applying elbow restraints as ordered prevents the infant from touching or injuring the surgical site, promoting healing.
E: Maintaining IV therapy for nutrition is important postoperatively to ensure the infant receives adequate nutrition and hydration for healing.
Summary of Incorrect Choices:
B: Encouraging the parents to hold the baby is generally beneficial for bonding and comfort but may risk disrupting the surgical site.
C: Administering aspirin for pain is contraindicated in infants due to the risk of Reye's syndrome.
Rationale:
A: Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration, promotes drainage, and reduces stress on the surgical site.
D: Applying elbow restraints as ordered prevents the infant from touching or injuring the surgical site, promoting healing.
E: Maintaining IV therapy for nutrition is important postoperatively to ensure the infant receives adequate nutrition and hydration for healing.
Summary of Incorrect Choices:
B: Encouraging the parents to hold the baby is generally beneficial for bonding and comfort but may risk disrupting the surgical site.
C: Administering aspirin for pain is contraindicated in infants due to the risk of Reye's syndrome.