Health Promotion and Maintenance
92. A nurse is working with a nursing student in caring for an infant who has just returned from the surgical recovery area following a cleft lip repair. Which action by the nursing student should cause the nurse to intervene?
. Placement of elbow restraints on the infant.
. Offering the parents a regular bottle with which to feed the infant.
. Positioning the infant in the semi-Fowler's position.
. Advising the parents of a plan to administer pain medication around the clock.
Test-Taking Tip
The question calls for an answer about what is not okay.
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Supervision
Health Promotion and Maintenance
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Answer 1 is incorrect because restraints are indicated in the care of a child who has had a cleft lip repair, to prevent the child from poking or pulling at the suture line. Answer 2 is correct because the infant should not be fed using a regular bottle. Postoperative feedings for the child with a cleft lip should be administered through special feeders to minimize trauma to the suture line. Since a cleft lip repair involves only the child's upper lip, the nurse should perform interventions that reduce the risk of damage or infection at the operative location. Answer 3 is incorrect because this is the correct position for a child following cleft lip repair, to promote drainage of mucus and decrease risk of aspiration. Answer 4 is incorrect because the child should be given pain medication on a schedule, to minimize pain-induced crying episodes that can put undue tension on the suture line.