Nokea
Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
- A. Feeding the infant with a spoon to avoid sucking
- B. Positioning the infant on the abdomen to facilitate drainage
- C. Applying elbow restraints to protect the surgical area
- D. Providing minimal stimulation to prevent injury to the incision
Correct Answer: C
Rationale: Elbow restraints are used postoperatively to prevent the infant from damaging the surgical area of a cleft lip repair.
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Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?
- A. Immediately after birth
- B. By 3 months of age
- C. After 12 months of age
- D. Varies in every case
Correct Answer: B
Rationale: A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.
What should the nurse assess for with this neonate?
- A. Hypoglycemia
- B. Erythroblastosis fetalis
- C. Intracranial hemorrhage
- D. Pancreatic failure
Correct Answer: A
Rationale: The newborn of a mother with diabetes is prone to hypoglycemia due to hyperinsulinism after the abrupt loss of maternal glucose.
Which statement indicates that parents understand how to feed their infant who had a surgical repair for a cleft lip?
- A. We are feeding the baby with a dropper for 2 weeks.'
- B. We resumed bottle feeding after discharge.'
- C. We started the baby on solid food yesterday.'
- D. The baby is drinking well from a straw.'
Correct Answer: A
Rationale: The infant is fed with a dropper until the cleft lip incision is completely healed, about 1 to 2 weeks after surgery.
What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?
- A. Prop the child upright with pillows for meals.
- B. Use the bar between the legs to turn the child.
- C. Put the child on her abdomen to sleep.
- D. Change the child's position frequently.
Correct Answer: D
Rationale: Frequent position changes relieve pressure and promote circulation in a toddler with a body spica cast.
What nursing action is most important for this nurse to implement?
- A. Align the limbs.
- B. Support the head.
- C. Keep the head lower than the hip.
- D. Check intake and output.
Correct Answer: B
Rationale: The child with hydrocephalus has a heavy head on a small body with poor muscle tone; supporting the head during feeding and moving prevents neck injury.