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. After 8 weeks in the neonatal intensive care unit, Chris will soon be discharged. His parents seem apprehensive and worry that he may still be in danger. What is this considered by the nurse?

Correct answer: A

Rationale: Parents become apprehensive and worried as the time for discharge approaches, which is a common parental reaction. They often have concerns and insecurities about caring for their infant. The worry about potential dangers is a normal adaptive response reflecting the parents' concern for their child's well-being. It is essential for healthcare providers to acknowledge these feelings and support parents in gaining confidence in caring for their infant. Choices B, C, and D are incorrect because the parents' apprehension in this context is a typical emotional response and not indicative of maladaptation, a reason to postpone discharge, or inadequate bonding.

3. Which parameter correlates best with measurements of total muscle mass?

Correct answer: D

Rationale: Upper arm circumference correlates best with total muscle mass because it includes both muscle and fat components, making it a reliable indicator of muscle mass.

4. What is one focus of current health care?

Correct answer: B

Rationale: The correct answer is 'Disease prevention.' Modern healthcare places emphasis on preventing diseases to enhance overall health and well-being. While nursing services, symptom management, and disease identification are crucial components of healthcare, disease prevention plays a key role in reducing the burden of illness on individuals and communities.

5. The nurse is caring for an adolescent who has just started dialysis. The child always seems angry, hostile, or depressed. The nurse should recognize that this is most likely related to what underlying cause?

Correct answer: D

Rationale: Adolescents may feel anger and depression due to the loss of independence and control over their lives, which is imposed by the need for regular dialysis treatments. This reaction is common as they struggle with the restrictions placed on their social and personal lives.

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