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?
A Apply and release elbow restraints every hour
B Keep the infant supine
C Feed the infant with a spoon for 48 hours
D Suction the mouth with an oral suction tube
The correct answer and Explanation is :
The correct answer is B: Keep the infant supine.
Explanation:
Cleft palate repair is a delicate surgical procedure that involves correcting an opening in the roof of the mouth (palate) to restore function and improve speech development. Postoperative care is crucial to promote healing and prevent complications.
B: Keep the infant supine
Placing the infant in a supine position (lying on their back) helps protect the surgical site and promotes proper healing. Lying prone (on the stomach) or on the side could apply pressure on the surgical area or cause unintentional trauma, such as rubbing or hitting the repaired palate. Keeping the infant supine also reduces the risk of aspiration or respiratory difficulties, which is important for maintaining a clear airway postoperatively.
A: Apply and release elbow restraints every hour
Elbow restraints are commonly used after cleft palate repair to prevent the child from touching their face or placing objects into their mouth, which could disrupt the sutures and compromise healing. However, the correct protocol typically involves releasing the restraints every 2 hours to allow for movement and circulation. Releasing them every hour could be excessive and unnecessary.
C: Feed the infant with a spoon for 48 hours
Using a spoon to feed an infant post-cleft palate repair is contraindicated. Feeding methods that involve placing objects in the mouth, such as spoons, pacifiers, or bottles, should be avoided because they could interfere with the surgical site. Infants are typically fed using specialized feeding bottles or soft-tipped syringes to prevent injury to the palate.
D: Suction the mouth with an oral suction tube
Routine suctioning with an oral suction tube is discouraged after cleft palate repair because it can damage the delicate tissue and sutures at the surgical site. If suctioning is necessary, it should be done very gently and only when absolutely required. Nasal suctioning is typically safer if airway clearance is necessary.