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NCLEX-RN · Question #751

NCLEX-RN Question #751: Real Exam Question with Answer & Explanation

The correct answer is B. Maintain elbow restraints in place unless she is being directly supervised.. (A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a

Question

A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

Options

  • APosition on side or abdomen.
  • BMaintain elbow restraints in place unless she is being directly supervised.
  • CClean suture line every shift.
  • DOffer pacifier when she cries.

Explanation

(A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and

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