the nurse is caring for an infant after a cleft lip repair which of these measures should be included in the plan of care
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The nurse is caring for an infant after a cleft lip repair. Which of these measures should be included in the plan of care?

Correct answer: C

Rationale: The correct measure that should be included in the plan of care for an infant after a cleft lip repair is to position the infant supine. Placing the infant in a supine position helps protect the surgical site from injury and promotes proper healing. Choice A, 'Position prone,' is incorrect as placing the infant prone can put pressure on the surgical site and hinder healing. Choice B, 'Provide fluids from a cup,' is not directly related to the surgical care of a cleft lip repair. Choice D, 'Avoid elbow restraints,' is not specific to the postoperative care of a cleft lip repair.

2. Identification and treatment of cryptorchid testes should be done by age 2 years. What is an important consideration?

Correct answer: B

Rationale: Early treatment of cryptorchidism is essential to preserve fertility and prevent complications such as testicular cancer. Surgery is usually well-tolerated, and sexual reassignment is not typically related to this condition.

3. Which describe the feelings and behaviors of early preschool children related to divorce? (Select all that apply.)

Correct answer: D

Rationale: Preschool children may exhibit regressive behavior, fear abandonment, and blame themselves for their parents' divorce due to their limited understanding of the situation.

4. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

5. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?

Correct answer: B

Rationale: Overeating, swallowing excessive air (leading to frequent burping), and parental smoking are known to contribute to colic in infants. Understimulation is not typically associated with colic.

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