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. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

3. A child who weighs 10 kg is to receive Motrin 8 mg/kg po q4h prn for pain. The label reads 100 mg/5 mL. How much will you administer?

Correct answer: A

Rationale: To calculate the dosage, multiply the child's weight (10 kg) by the dosage (8 mg/kg) which equals 80 mg. Since the concentration is 100 mg/5 mL, to find out how much to administer, you need to determine how many 5 mL doses are in 80 mg. It will be 80 mg ÷ 100 mg * 5 mL = 4 mL. Therefore, the correct answer is 4 mL. Choice B, 2 mL, is incorrect because it does not account for the correct dosage calculation. Choice C, 5 mL, is incorrect as it does not consider the dosage based on the child's weight. Choice D, 3 mL, is incorrect as it does not reflect the accurate dosage calculation.

4. During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?

Correct answer: C

Rationale: Significant head lag at 8 months is concerning and warrants further evaluation, as it may indicate developmental delays or neurological issues.

5. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

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