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Exam NCLEX-RN topic 7 question 57 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 57
Topic #: 7
[All NCLEX-RN Questions]

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?

  • A. Position on side or abdomen.
  • B. Maintain elbow restraints in place unless she is being directly supervised.
  • C. Clean suture line every shift.
  • D. Offer pacifier when she cries.
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Suggested Answer: B 🗳️
(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 cause scarring.
by [deleted] at March 10, 2025, 7:17 a.m.

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