Question

A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

Answer 1

Correct Answers:

Apply and release elbow restraints every hour

Rationale :

💪 After a cleft palate repair, elbow restraints are typically used to prevent the infant from touching or disrupting the surgical site.

💪 The nurse should apply and release the restraints every hour to allow for circulation, comfort, and ensure skin integrity.

💪 Restricting excessive movement is essential to promote healing.

💪 Supine positioning is usually recommended to keep the surgical site clean and stable, but it should not be the focus over safe handling.

💪 Feeding with a spoon may be advised after healing but not within the immediate postoperative period.

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Answer 2

Correct Answers:

Place the infant on his left side

Rationale :

💤 After feeding, placing an infant with gastroesophageal reflux (GERD) on their left side helps decrease acid reflux.

💤 The left side position promotes gravity-driven drainage and decreases the chance of reflux back into the esophagus.

💤 The prone position is not safe in infants due to SIDS risk.

💤 The right side may increase gastric emptying, but it’s less effective than the left side.

💤 Infant seat positioning can help, but it should not replace proper sleep positioning.

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Answer 3

Correct Answers:

Water

Rationale :

💧 After tonsillectomy, the child should be encouraged to drink cool fluids to keep the throat moist, reduce pain, and avoid dehydration.

💧 Water is the best option as it is gentle, hydrating, and unlikely to irritate the healing tonsillar site.

💧 Cranberry juice is acidic and can irritate the sensitive throat.

💧 Milkshake may coat the throat but could cause mucus production.

💧 Ice cubes or crushed ice may be used to help numb the area, but water remains the safest and most soothing option.

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Answer 4

Correct Answers:

We will rotate the probe of the pulse oximeter every 24 hours.

Rationale :

🩺 The pulse oximeter probe should be rotated regularly to prevent skin breakdown and ensure accurate readings.

🩺 Keeping the probe on the same location for extended periods can cause pressure injuries.

🩺 Accurate readings are vital, and parents should be instructed to not rely on the same spot for long periods.

🩺 100% saturation is rare, but low readings are concerning. Parents should not notify the doctor based solely on 100% readings.

🩺 The pulse oximeter probe can be applied to either the toe or finger, and monitoring is done frequently for accuracy.

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Answer 5

Correct Answers:

Administer sodium biphosphate/sodium phosphate.

Rationale :

⚠️ Sodium biphosphate/sodium phosphate is used to prepare the bowel in cases of appendicitis to ensure that the colon is empty and prevent complications during surgery.

⚠️ NPO status is essential to avoid aspiration and dehydration, but bowel prep is a standard part of care.

⚠️ Temperature monitoring every 4 hours is typical, but not a priority for immediate concerns.

⚠️ The child should receive pain management, but administering it frequently without assessing the cause could mask signs of peritonitis.

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Answer 6

Correct Answers:

Abdomen distended with visible mass noted in right upper quadrant

Rationale :

🩺 A distended abdomen with a palpable mass could be indicative of a serious condition such as a congenital anomaly or tumor that requires immediate provider assessment.

🩺 Normal findings in 2-month-olds include appropriate skin tone, warm dry skin, and a normal range of motion.

🩺 Visible masses or abdominal distension are red flags and need urgent attention.

🩺 Normal findings would not include mass palpation or visible enlargement of organs.

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Answer 7

Correct Answers:

Respiratory rate: 28/min

Rationale :

💨 A respiratory rate of 28/min is within normal limits for a 2-month-old infant, where the typical range is 30–60 breaths per minute.

💨 Axillary temperature of 37.1°C (98.8°F) and a heart rate of 130/min are also within normal ranges for this age.

💨 Current weight of 3.26 kg is below average but still within acceptable ranges for an infant who was likely born premature, so it is not immediately concerning.

💨 There is no immediate concern based on the current vital signs provided.

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Answer 8

Correct Answers:

Pyloric stenosis

Rationale :

🔴 The infant’s symptoms of projectile vomiting, increased fussiness, and vomiting after feedings are classic signs of pyloric stenosis.

🔴 Pyloric stenosis is a narrowing of the pyloric sphincter, preventing food from entering the small intestine, leading to vomiting.

🔴 This condition often presents at 3-6 weeks of life with non-bilious, projectile vomiting, and may require surgical intervention.

🔴 Gastroesophageal reflux (GERD)could cause some vomiting but does not typically cause projectile vomiting.

🔴 Celiac disease and lactose intolerance present differently, usually with chronic diarrhea or constipation, not projectile vomiting.

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Answer 9

Correct Answers:

My child will take the enzymes to help digest the fat in foods-

Rationale :

🧴 In cystic fibrosis (CF), pancreatic enzymes help break down and absorb fat, proteins, and carbohydrates that the pancreas cannot properly digest due to blocked ducts.

🧴 These enzymes should be taken with every meal and snack to ensure proper digestion and absorption of nutrients.

🧴 The child should not take enzymes before meals or with an empty stomach as they are essential for breaking down the food in the digestive system.

🧴 It is essential for the parent to understand the purpose of the enzymes to support proper nutrition and growth in CF children.

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Answer 10

Correct Answers:

"Bring your baby in to the clinic today."

Rationale :

🩺 Projectile vomiting in a 2-month-old is concerning for pyloric stenosis, a surgical emergency that causes intestinal obstruction.

🩺 This condition typically presents with projectile vomiting of partially digested food shortly after feeding.

🩺 The infant should be evaluated immediately in a clinical setting to confirm the diagnosis and begin treatment.

🩺 Oral rehydration solutions and frequent burping may help in cases of GERD, but this is not the primary concern here.

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QLexNursing

1 :
A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

2 :
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings?

3 :
A nurse is caring for a child who is 2 hours postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

4 :
A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

5 :
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

6 :
A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

7 :
A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

9 :
A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements by the mother indicates that she understands the teaching?

10 :
A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

QLexNursing

1 : A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

2 : A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings?

3 : A nurse is caring for a child who is 2 hours postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

4 : A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

5 : A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

6 : A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

7 : A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

9 : A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements by the mother indicates that she understands the teaching?

10 : A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

1 :
A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

2 :
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings?

3 :
A nurse is caring for a child who is 2 hours postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

4 :
A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

5 :
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

6 :
A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

7 :
A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

9 :
A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements by the mother indicates that she understands the teaching?

10 :
A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?