Difficulty: Medium
Average Score: 66%
Simulated
Passage / Scenario
A 2-month-old infant who has just undergone cleft palate repairA nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
Correct answer
C,D
Rationale
Correct Answer: C, D
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.