A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which of these nursing actions should be the priority?
A. Utilize bilateral elbow restraints at all times
B. Initiate formula/breast feedings for infant when alert
C. Reinforce about steps to cleanse the suture line with a peroxide solution D. Position the infant after feedings in a supine position, propped up on a pillow
Utilize bilateral elbow restraints at all times-the correct answer is a: utilize bilateral elbow restraints at all times.the major efforts in the post operative period are directed toward protecting the operative site. elbow restraints should be used and only one arm released at a time with close supervision by the nurse and/or parents. usually diluted peroxide solutions are used for suture cleansing.test-taking tips:the key words or clues in this question are: two-month-old, cleft lip repair, immediate post-op, and priority nursing action. although there is an absolute word in option 1 (all), when you ask yourself is this true? consider why it may be correct. the natural response of this age child would be to touch the operative site. ask yourself: what problems could this cause in relation to abcs? it is not an abc priority but a safety issue - a safety hazard to the operative site.